Hampshire and Isle of Wight Guidelines for in the Community

Transcription

Hampshire and Isle of Wight
Guidelines for Antibiotic Prescribing
in the Community 2012
Adapted from the Health Protection Agency and British Infection
Association Management of Infection Guidance for Primary Care
by the Antibiotic Sub-group of the Hampshire and Isle of Wight
Committee for Healthcare-Associated Infections (CHAIN)
Foreword
These guidelines are intended to provide advice on the effective and safe treatment of infections commonly presenting in
adults and children in the primary care setting in Hampshire and the Isle of Wight. The guidelines also promote the use of
narrow-spectrum antibiotics in preference to broad-spectrum antibiotics where safe and appropriate. The audience of users
is anticipated to be general practitioners, GP trainees, GP practice nurses, non-medical prescribers, paramedics, hospital
emergency department staff and community pharmacists.
The multi-disciplinary guideline development group consisted of general practitioners, hospital consultant medical
microbiologists, a consultant in HIV / genito-urinary medicine, specialist hospital microbiology / infectious diseases pharmacists,
primary care trust and ambulance trust pharmacists and a senior podiatrist (see below).
The guidelines have been updated from the previous version, published in 2008, taking into consideration feedback from
users, emerging evidence and changing epidemiology of antimicrobial resistance. The guidelines are based largely on the
Management of Infection Guidance for Primary Care, published jointly by the Health Protection Agency and the British
Infection Association, updated in January 2012, and the guideline development group gratefully acknowledges the work of
Dr Cliodna McNulty and her colleagues in the HPA and BIA.
Recommendations for when antimicrobial treatment is indicated, based upon cited national or international evidence-based
guidelines, have been expanded from the HPA/BIA Guidance, along with recommendations and practical advice for taking
specimens for microbiological investigations and interpreting culture and sensitivity laboratory reports. Clinically relevant
information on cautions and warnings associated with antimicrobial treatment have also been expanded from the HPA/BIA
Guidance including information about risk of Clostridium difficile infection. All statements are fully referenced.
The guidelines were developed during 2011 and early 2012 and published in April 2012. The guidelines are scheduled for
review in April 2014.
Comments and feedback are welcome; please e-mail [email protected] or [email protected].
Reference
Shaneyfelt TM, Mayo-Smith MF & Rothwangl J. Are Guidelines Following Guidelines?
The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature. JAMA. 1999; 281: 1900-1905.
page 1
Guideline Development Group
Anita Bhardwaj, HIV Specialist Pharmacist, Southampton Sexual Health Services
Janet Brember, Interface / Formulary Pharmacist, NHS Portsmouth
Caroline Bowyer, Chief Pharmacist, Solent NHS Trust
Tina Chambers, Clinical Nurse Specialist in Tissue Viability, Hampshire Hospitals NHS Foundation Trust (HHNFT)
Dr Helen Chesterfield, Consultant Medical Microbiologist, Portsmouth Hospitals
Debbie Cumming, Antibiotic Pharmacist, Isle of Wight NHS Trust
Dr Madelyn Dakeyne, GP Eastleigh, and District Prescribing Committee
Dr Matthew Dryden, Consultant Medical Microbiologist, Royal Hampshire County Hospital, HHNFT
Ruth Ellenby, Medicines Management Pharmacist, North Hampshire Clinical Commissioning Group
Carole Endean, Specialist Pharmacist, Basingstoke Hospital, Hampshire Hospitals NHS Foundation Trust
Ed England, Pharmacy Advisor, South Central Ambulance Service NHS Trust
Dr Elizabeth Fellows, GP, Portsmouth
Joanna Gibson, Specialist Pharmacist, University Hospital Southampton NHS Foundation Trust (UHSNFT)
Dr Kieran Hand, Consultant Pharmacist Anti-Infectives, UHSNFT
Kathleen Hayes, Pharmacist, Medicines Management Team, Solent NHS Trust
Taryn Keyser, Antimicrobial/Critical Care Pharmacist, Basingstoke Hospital, HHNFT
Alma Kilgarriff, CCG Lead Pharmacist, North Hampshire Clinical Commissioning Group
Margaret Nicholls, Senior Clinical Pharmacist, Southern Health NHS Foundation Trust
Natalie Parker, Antibiotic Pharmacist, Royal Hampshire County Hospital, HHNFT
Dr Roberta Parnaby, Consultant Medical Microbiologist, Royal Hampshire County Hospital, HHNFT
Dr David Rowen, Consultant GU/HIV Medicine, Solent NHS Trust
Dr Kordo Saeed, Consultant Medical Microbiologist, Royal Hampshire County Hospital, HHNFT
Adel Sheikh, Antibiotic / Respiratory Directorate Pharmacist, Portsmouth Hospitals NHS Trust
Dr Julian Sutton, Consultant in Infectious Diseases & Medical Microbiology, UHSNFT
Sharon Tuck, Podiatry Pathway Lead, Solent Healthcare
Mike Vickers, Specialist Pharmacist, UHSNFT
Dr Nigel Watson, Chief Executive, Wessex Local Medical Committees Ltd. Chandler’s Ford
Andrea White, Locality Senior Pharmacist, Prescribing team, NHS Southampton
Dr Sarah Wylie, Consultant Medical Microbiologist, Portsmouth Hospitals NHS Trust
page 3
Aims
• to provide a simple, empirical approach to the treatment of common infections
• to promote the safe, effective and economic use of antibiotics
• to minimise the emergence of bacterial resistance in the community
Principles of Treatment (HPA/BIA)
1.This guidance is based on the best available evidence, as referenced, but professional judgement should be used and patients
should be involved in the decision.
2.A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal
function. In severe or recurrent cases consider a larger dose or longer course.
3.Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice.
4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
5. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.A+
6. Limit prescribing over the telephone to exceptional cases.
7.Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (eg co-amoxiclav, quinolones and cephalosporins)
when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs.
8.Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g. fusidic acid).
9.In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole (2g). Short-term use of
nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus. Trimethoprim also
unlikely to cause problems unless poor dietary folate intake or taking another folate antagonist such as antiepileptic.
10.We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times
daily & generic tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
11.Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from your local
hospital microbiology department.
page 5
Risk assessment
Risk of Clostridium difficile infection
Risk of antibiotic treatment failure
Patient
Older patients (over 65yr) & antibiotic exposure within
previous 2 months
History of infection with resistant microorganism.
Recent antibiotic exposure. Immunocompromised.
Environment
Contact with patients with Clostridium difficile or recent
hospital admission
Infection acquired in healthcare environment
Action
Withhold antibiotics if safe to do so (watchful waiting).
Avoid high risk antibiotics (the 4 Cs):
• Cephalosporins
• Ciprofloxacin & quinolones
• Co-amoxiclav
• Clindamycin
(indicated by an asterisk in the following tables)
Consider second-line antibiotics from the
following tables
Evidence Grading
Study design
Recommendation grade
Good recent systematic review of studies
A+
One or more rigorous studies, not combined
A
One or more prospective studies
B+
One or more retrospective studies
B-
Formal combination of expert opinion
C
Informal opinion, other information
D
page 7
Index
1.Ear Nose and Throat Conditions 1.1 Acute Sore Throat
1.2 Acute Otitis Media
1.3 Acute Otitis Externa
1.4 Acute Sinusitis
11
12
13
14
2.Respiratory Tract Infections
2.1 Acute Bronchitis
15
2.2Influenza
16
2.3 COPD Acute Exacerbation
17
2.4Community Acquired
Pneumonia18
3. Central Nervous System
3.1Meningitis or Suspected
Meningococcal Disease
19
4. Urinary Tract Infections
4.1Uncomplicated UTI
in Women
21
4.2 Lower UTI in Pregnancy
22
4.3 Lower UTI in Men
23
4.4 Catheter associated UTI
24
4.5 UTI in Children
25
4.6Recurrent UTI in Women –
prophylaxis26
4.7 Acute Pyelonephritis
27
5. Genital Tract Infections
5.1.Criteria for referring to
specialist care
29
5.2. Vulvo Vaginal Candidiasis 30
5.3. Bacterial Vaginosis
31
5.4.Chlamydia trachomatis32
5.5.Trichomoniasis
33
5.6. Pelvic Inflammatory Disease 34
5.7. Acute Prostatitis
35
5.8.Balanitis
36
5.9.Epididymo-orchitis
37
6. Gastro-intestinal Infections
6.1.Eradication of Helicobacter
pylori39
6.2. Infectious Diarrhoea
40
6.3.Diverticulitis
41
6.4.Clostridium difficile42
6.5. Traveller’s Diarrhoea
43
6.6.Threadworms
44
7. Skin & Soft tissue Infections
7.1.Impetigo
7.2.Eczema
7.3.Cellulitis
7.4. Leg ulcers
45
46
47
48
7.5. Diabetic foot ulcer
7.6.MRSA
7.7. Animal Bite
7.8. Human Bite
7.9.Scabies
7.10.Fungal infection – skin
7.11.Fungal infection – fingernail
or toenail
7.12.Varicella zoster/chicken pox
& Herpes zoster/shingles &
Cold Sores
7.13.Acne vulgaris
49
50
51
52
53
54
56
57
8.Eye Infections
8.1Conjunctivitis
59
55
9.Dental Infections
9.1.Mucosal ulceration and
inflammation61
9.2Acute necrotising ulcerative
gingivitis (ANG) and
Pericoronitis (PC)
62
9.3 Dental Abscess
63
page 9
Ear Nose and
Throat Conditions
EN&T
Ear Nose and Throat Infections – Acute Sore Throat
When to treat1
Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours.1A+
If Centor score 3 or 4: (Lymphadenopathy; No cough; fever; tonsillar exudate)A- consider 2 or 3-day delayed or immediate
antibiotics.1A+
Average total length of illness is one week.2
Antibiotics to prevent quinsy NNT >4000.B- 1,2
Antibiotics to prevent otitis media NNT 200.1,2A+
When to investigate3 Throat swabs or rapid antigen tests should not be carried out routinely in the investigation of acute sore throat.2,3
Suspect glandular fever in a person with a sore throat that fails to improve, or becomes worse, after several days.3
If allergic to penicillin:
Clarithromycin 250-500mg bd for 5 daysA+
Treatment choices1
First line:
PhenoxymethylpenicillinB 500mg qds or 1g bdA+ for 10 daysA(1g qds when severeD)
Cautions3
Prescribing amoxicillin or ampicillin will produce a generalized, itchy maculopapular rash in over 90% of people with glandular fever.3
Evidence
• A recent (2009) meta-analysis shows short-course (including 5 days clarithromycin) broad-spectrum antibiotics are as efficacious as
10-day penicillin for sore throat symptom treatment and GABHS eradication. A 10-day course of phenoxymethylpenicillin remains the
treatment of choice. Evidence suggests the use of broader spectrum antibiotics will drive the emergence of bacterial resistance; increases
the risk of developing Clostridium difficile associated disease; and is associated with more adverse drug reactions. 5-days clarithromycin
should be reserved for those with true penicillin allergy.1
• Glomerulonephritis is a rare condition, (2.1 per 100,000 children per year) and treating acute sore throat with antibiotics doesn’t
prevent it occurring.1
• A retrospective study confirmed the low incidence of Rheumatic Fever in the UK, (0.6 per 100,000 children per year). The risk of
developing Rheumatic Fever was not reduced in this study by treating sore throats with antibiotics.1
References
1. M
anagement of Infection Guidance for Primary Care, HPA & BIA, Jan 2012. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
2. N
ICE. National Institute for Health and Clinical Excellence. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008.
(Clinical guideline 69) http://guidance.nice.org.uk/CG69
3. PRODIGY Sore Throat – Acute. http://prodigy.clarity.co.uk/sore_throat_acute/management (Accessed January 2012)
page 11
Ear Nose and Throat Infections – Acute Otitis Media (AOM)
When to treat1
Optimise analgesia and target antibiotics.1BAOM resolves in 60% within 24h without antibiotics, which only reduce pain at 2 days (NNT15) and do not prevent deafness.1A+
Consider 2 or 3-day delayed antibiotic prescription.1A+ Consider offering immediate antibiotics for pain relief if:
• <2 years AND bilateral AOM (NNT4) or bulging membrane & ≥ 3 marked symptoms 1A+
• All ages with otorrhoea (discharge in the ear canal) NNT3 1A+
Antibiotics to prevent mastoiditis NNT >4000 1B-
When to investigate Routine follow up is not required in the absence of persistent symptoms.2
General advice1
Average total length of illness is 4 days.3
Both paracetamol and ibuprofen showed a non-significant trend towards effective analgesia compared with placebo.4
Treatment choices
(child doses)1
First-line:
AmoxicillinA+ 13.5mg/kg tds (max 500mg tds)Bfor 5 daysA+
Cautions
Admission or immediate referral if: suspected acute complications of acute otitis media (AOM), such as meningitis, mastoiditis, or
facial paralysis.2 Consider admitting children < 3 months of age with a temperature of 38°C or more, and children 3–6 months of age
with a temperature of 39°C or more.4
Elective referral if: Persistent effusion or discharge, perforation not healed after 6 weeks, 4 or more episodes in 6 months or impaired
hearing after 3 to 6 months.2
Note: children with serious craniofacial abnormalities or immune deficiencies that are not responding to primary care management are
at high risk of developing head and neck complications.2
Evidence
Amoxicillin is as effective as other antibiotics in the treatment of AOM in RCTs.1
Macrolides concentrate intracellularly and so are less active against the extracellular H influenzae.D
No advantage in using an antibiotic to cover beta-lactamase resistant organisms (e.g. co-amoxiclav) in the initial treatment of AOM as
should be reserved for persistent acute otitis media.2
References
1. M
anagement of Infection Guidance for Primary Care, HPA & BIA, Jan 2012. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
2. PRODIGY Otitis Media – Acute. http://prodigy.clarity.co.uk/otitis_media_acute Accessed January 2012
3. NICE. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical guideline 69) http://guidance.nice.org.uk/CG69
4. NICE. Feverish illness in children. 2007. (Clinical Guideline 47). http://publications.nice.org.uk/feverish-illness-in-children-cg47
5. BNF for children 2011-12
If allergic to penicillin: ClarithromycinD for 5 daysA+
Under 8kg: 7.5mg/kg bd
8-11kg:62.5mg bd 12-19kg:125mg bd
20-29kg:187.5mg bd
30-40kg:250mg bd
12-18 years: 250mg bd
(Increased to 500mg bd
if required in severe infection5)
page 12
Ear Nose and Throat Infections – Acute Otitis Externa
When to treat1
When to
investigate2
How to respond
to a positive lab
report2
First use aural toilet (if available) & analgesia.1 Cure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid .1A+
Consider seeking specialist advice if an oral antibiotic is thought to be required (start oral antibiotics and refer 2A+), such as for:
• Cellulitis extending beyond the external ear canal
• When the ear canal is occluded by swelling and debris, and a wick cannot be inserted.
• Diabetes or compromised immunity, and severe infection or high risk of severe infection, e.g. with Pseudomonas aeruginosa
Investigation is not routinely required. Laboratory investigations are rarely useful. However, if the treatment strategy fails, consider taking
an ear swab for bacterial and fungal microscopy and culture.
A swab is best taken from the medial aspect of the ear canal under visualisation to reduce contamination.
Identifying the organism, and especially distinguishing a fungal from a bacterial infection, can be of therapeutic significance. However,
interpretation of culture results is difficult:
Reported bacterial susceptibility may not correlate with clinical outcomes because sensitivities are determined for systemic (not topical)
administration. Much higher concentrations of antibiotic can be achieved with topical application.
It is not possible to tell from the culture results whether the isolated organisms are causing the disease or are merely contaminants. In
particular, there is likely to be a fungal overgrowth after using antibacterial drops as these will have suppressed the normal bacterial flora.
Treatment choices1 First-line: ear drops / spray
Acetic acid (EarCalm spray®)
2% one spray tds for 7 days.1,2
Available over-the-counter from pharmacies.
Second-line: ear drops / spray
Neomycin + steroid three drops
tds for 7- 14 days.1,2 A+
Oral antibiotics are rarely indicated2
Flucloxacillin 500mg
qds for 7 days2
Clarithromycin 500mg
bd for 7 days2
Cautions
Aminoglycosides (e.g. neomycin and gentamicin) are contraindicated with perforated eardrum. However, many specialists do use these
drops cautiously in the presence of a perforation in patients with otitis externa when other measures have failed (BNF63).
Malignant Otitis Externa is an aggressive infection that affects the immunocompromised and elderly that requires prompt hospital
admission.1 Facial nerve paralysis may be an early sign. GPs should refer severe cases, characterised by unremitting pain, cranial nerve
deficits, perforated tympanic membrane or history of previous ear surgery.1
Evidence
Acetic acid was as effective and comparable to antibiotic/steroid for the first 7 days, but inferior after this point.1 It is important to instruct
patients to use drops for at least one week, and to continue for up to 14 days if symptoms persist. The oral antibiotics in the trials were
often inactive against P. aeruginosa (incidence 36%) and S. aureus (incidence 21%).1 Topical antibiotics such as neomycin have a broader
spectrum of activity. When using topical antibiotics in the ear bacterial resistance is less of a concern as the high local concentration of the
drug will generally eradicate all susceptible organisms, plus those with marginal resistance.1
References
1. Management of Infection Guidance for Primary Care, HPA & BIA, Jan 2012. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
2. PRODIGY Otitis Externa. http://prodigy.clarity.co.uk/otitis_externa (Accessed January 2012)
page 13
Ear Nose and Throat Infections – Acute Sinusitis
When to treat
When to investigate
Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days (NNT15). 1,2A+
NICE estimates that the average duration of acute sinusitis is 2.5 weeks.2 A systematic review analysed the placebo arms of several
randomized controlled trials (RCTs), and found that, after 7–15 days, 73% of people taking placebos experienced some improvement in
their symptoms, and 30% had complete recovery.3
Use adequate analgesia.1,2B+ Consider 7-day delayed or immediate antibiotic when purulent nasal discharge (NNT8).1A+
Consider an immediate antibiotic prescription3 only if it is not appropriate to admit the person and they are:
• Systemically unwell, or
• At high risk of complications because of a pre-existing comorbidity.
Investigations are not required in primary care because nasal swabs for culture have a poor diagnostic yield and are frequently
contaminated (or bacteria found are commensal).3
Doxycycline1 200mg stat,100mg
od for 7 days1A+
(200mg daily for severe infections4).
Second line:
In persistent infection use an agent
with anti-anaerobic activity such as
Co-amoxiclav1* 625mg tds for
7 days1A+
Treatment choices1
First-line:
Amoxicillin1A+ 500mg (1g if severe1D) tds for 7 days1A+ or
Doxycycline1 200mg stat then 100mg od for 7 days
(200mg daily for severe infections4).
Some hospital specialists may prescribe high-dose doxycycline
200mg bd for 2 days then 200mg od for 4 days.D
Cautions3
Admit to hospital if there is severe systemic infection, or if a complication of sinusitis is suspected.3 Suspect intra-orbital involvement if
there is peri-orbital oedema, a displaced globe, double vision, ophthalmoplegia, or reduced visual acuity. Suspect intracranial involvement
if there is a severe frontal headache, frontal swelling, symptoms or signs of meningitis, or focal neurological signs.3
Consider urgent referral to an Ear, Nose, and Throat (ENT) department if the person is suspected of having a sinonasal tumour (persistent
unilateral symptoms, such as bloodstained discharge, crusting, non-tender facial pain, facial swelling, or unilateral nasal polyps).3 Consider
routine referral to ENT if the person has frequent recurrent episodes of sinusitis which are troublesome (such as more than three episodes
requiring antibiotics in a year).
Seek specialist advice if second-line antibiotics have been ineffective.3 Doxycycline is contra-indicated in children <12yrs.4
* High-risk drug for Clostridium difficile infection and should be avoided in at-risk patients
Evidence
S. pneumoniae susceptibility to tetracycline is falling in the UK (currently 88.1%) but H. influenzae susceptibility to tetracycline is 98.7%
compared with co-amoxiclav at 93%.5
References
3 PRODIGY Sinusitis. http://prodigy.clarity.co.uk/sinusitis (Accessed January 2012)
4. BNF 63. March 2012.
5. British Society for Antimicrobial Chemotherapy Resistance Surveillance Project. www.bsacsurv.org 2009-10
page 14
Respiratory Tract
Infections
RTI
NationalInfections
Library for Health–Clinical
Knowledge
Summary
Chronic Obstructive Pulmonary Disease www.cks.library.nhs.uk
References Tract
Respiratory
Acute
Cough,
Bronchitis
When to treat
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation & local adaptation. 5 June 2008.
www.hps.org.uk
Presents as cough with or without sputum, breathlessness, wheeze or general malaise. There are no chest signs other than wheeze and
Chronic Obstructive Pulmonary Disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in
crackles.
If crackles
present,
they
should
clear with coughing – if they persist, diagnose pneumonia.1
primary and
secondary
care Thoraxare
2004:59
(Suppl.
1);i1-232.
www.thorax.bmj.com
Antibiotics are not routinely indicated if the patient has no co-morbidities as they offer little benefit and may cause side effects.1,2,3
Viruses are responsible for more than 90% of acute bronchitis infections.4
Studies show antibiotics reduce symptoms of cough and feeling ill by less than one day in an illness lasting several weeks in total.2
Consider prescribing an antibiotic if the person has a significantly impaired ability to fight infection (e.g. immunocompromised status,
cancer, or those aged >75 with fever) or if acute bronchitis is likely to significantly worsen a pre-existing condition (e.g. heart failure,
COPD, angina, or diabetes).1 A delayed antibiotic prescribing strategy may be considered for people with acute bronchitis where it is felt
safe not to prescribe antibiotics immediately.1 Patients should be advised to use the prescription if symptoms are not starting to settle
within 2-3 weeks of their onset or if a significant worsening of symptoms occurs.3
When to investigate Routine follow-up is unnecessary.1 Re-examine people who have deteriorated to exclude pneumonia.1
Second line or if penicillin allergic:
Doxycycline 200 mg stat then 100 mg od
for 5 days total
Treatment choices1
First-line:
Amoxicillin 250-500mg tds for 5 days
General advice
Patients should be advised to use paracetamol or ibuprofen as required, drink plenty of fluids and to stop smoking.1
Advise patients that resolution of symptoms can take up to 3 weeks.2
Evidence
Cough medicines are not recommended, although they are unlikely to do harm. Some people may find simple remedies like honey and
lemon soothing.1
Clarithromycin is active against most pathogens involved in acute bronchitis, although resistance is increasing, especially in H. influenzae.1
Low doses of penicillins are more likely to select out resistance.2 Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor
pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms.2
References
1. PRODIGY 2010 Cough. http://prodigy.clarity.co.uk/cough (Accessed March 2012)
4. Albert R. Diagnosis and treatment of acute bronchitis. American Family Physician 2010; 82(11): 1345-1350
Third line:
Consider clarithromycin 250mg bd for
5 days if amoxicillin or doxycycline unsuitable.
page 15
Respiratory Tract Infections – Influenza
When to treat
Influenza is characterised by the sudden onset of fever, chills, headache, myalgia and extreme fatigue.1
Vaccination: Annual vaccination is essential for all those at risk of influenza.2 At-risk groups (not exhaustive – exercise clinical
judgement): ≥65 years old; chronic heart disease (not uncomplicated hypertension); chronic respiratory, kidney, liver or neurological
disease; diabetes; pregnant women (and up to 2 weeks post partum); immunocompromised individuals1; people living in long-stay
residential and nursing homes or other long-stay care facilities; all healthcare and social care staff directly involved in patient care (via
their occupational health dept.) and household contacts of immunocompromised individuals.3 The ideal time for immunisation is between
September and early November.1
Treatment: For otherwise healthy adults (unless pregnant), antivirals are not recommended unless it is thought the patient is at serious risk
of developing complications.4
If flu is circulating in the community and if a patient in an at-risk group can start treatment within 48h of onset of flu-like illness, oseltamivir or
zanamivir treatment is recommended.5 At risk: Pregnant women (including up to 2 weeks post partum); chronic respiratory, cardiac, renal, liver
or neurological disease; diabetes mellitus; 65 years or older; immunosuppressed; morbid obesity (BMI ≥40).4
For post-exposure prophylaxis, please consult most recent HPA or Department of Health guidance.
When to investigate Routine follow up in otherwise healthy patients is not necessary, but advise the person they should: Return if no improvement after
1 week or they are deteriorating; seek urgent medical attention if they develop shortness of breath, pleuritic chest pain or haemoptysis;
have a low threshold for seeking help if they are caring for a young child or baby with influenza, as children cannot accurately
communicate their symptoms.3
In at risk groups, consider follow up (particularly in frail people) after 1 week to confirm symptoms are improving and to exclude the
development of secondary complications.3
Treatment choices1
First line:4
In severely immunocompromised patients or where oseltamivir resistance is suspected:4
Oseltamivir 75 mg bd for 5 days. Zanamivir 10 mg (2 inhalations by diskhaler) bd for 5 days.
For paediatric dosing consult product literature or latest HPA guidance.
Evidence
After immunisation, antibody levels may take up to 10 to 14 days to reach protective levels.1
In healthy individuals, seasonal influenza is an unpleasant but usually self-limiting disease with recovery in 2–7 days.1
Treatment after 48 hours from symptom onset is an off-label use of oseltamivir and clinical judgement should be exercised.4
References
1. Department of Health Green Book Immunisation against infectious disease. Influenza. www.dh.gov.uk Last updated November 2011 (Accessed March 2012)
3. Prodigy 2007 http://www.prodigy.clarity.co.uk/chest_infections_adult (Accessed March 2012)
4. HPA guidance on antiviral agents for the treatment and prophylaxis of influenza 2011-12 www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131466016
page 16
Respiratory Tract Infections – COPD Acute Exacerbation
When to treat
Treat exacerbations promptly with antibiotics if increased purulence of sputum and one or both of increased shortness of breath or
increased sputum volume.1,2B+
Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on a chest
radiograph or clinical signs of pneumonia.3
Sending sputum samples for culture in primary care is of very limited value because empirical therapy is effective and should be prescribed
When to investigate promptly if the sputum is purulent. Sending sputum samples in practice is not routinely recommended.3
Pulse oximetry is of value if there are clinical features of a severe exacerbation.3 Consider hospital admission if oxygen saturation <90%.4
Treatment choices1
Amoxicillin1 500mg tds for 5 daysC
OR if allergic to penicillin:
Doxycycline1 200mg stat, 100mg od for 5 daysC (200mg daily for severe infections5).
Some hospital specialists may prescribe high-dose doxycycline 200mg bd for 2 days then
200mg od for 4 days.D
OR if allergic to penicillin & tetracyclines contra-indicated:
Clarithromycin1 500mg bd for 5 daysA
If resistance risk factors:
Co-amoxiclav1 625mg tds for 5 daysA
Risk factors for antibiotic resistant
organisms include co-morbid disease,
severe COPD, frequent exacerbations,
antibiotics in last 3 months.1
Cautions
The following physical signs are features of a severe exacerbation (consider hospitalisation): marked dyspnoea and tachypnoea; pursed-lip
breathing; use of accessory muscles at rest; acute confusion; new-onset cyanosis or peripheral oedema; marked reduction in activities of
daily living.4
Evidence
A meta-analysis of 21 double-blind RCTs involving 10,698 patients, concluded that a short course (≤5 days) of antibiotic treatment was
as effective as the traditional longer treatment in patients with mild to moderate exacerbations of chronic bronchitis and COPD.1
Patients who used antibiotics within 30-days of the index hospitalisation date experienced lower odds for all-cause 30-day mortality
after hospitalisation than those who did not receive antibiotics (OR 0.83, 95% CI, 0.75 to 0.92). In relation to antibiotic use, macrolides
had the lowest relative odds for mortality (OR 0.58, 95% CI 0.47 to 0.73) and fluoroquinolones had the highest relative odds (OR 0.98,
95% CI 0.84 to 1.15).3 Although quinolones have performed equally well in clinical trials of lower RTI, no clinical superiority over other
antibiotics has yet been shown.3 Do not use ciprofloxacin first-line due to poor pneumococcal activity. Reserve all quinolones for proven
resistant organisms.1
References
2. GOLD guidelines for COPD. December 2011. http://www.goldcopd.org/
3. NICE. Chronic obstructive pulmonary disease (updated). 2010. (Clinical Guideline 101) http://guidance.nice.org.uk/CG101
4. PRODIGY Chronic obstructive pulmonary disease. http://www.prodigy.clarity.co.uk/chronic_obstructive_pulmonary_disease (Accessed January 2012)
5. BNF 63 March 2012
page 17
Respiratory Tract Infections – Community-Acquired Pneumonia (CAP)
When to treat
The presence of either abnormal vital signs (fever >38°C, tachycardia >100/min and tachypnoea >20/min) or an abnormal physical
examination of the chest (crackles, decreased breath sounds, dullness to percussion, wheeze) identified patients with
radiographically confirmed CAP with a sensitivity of 95%, negative predictive value of 92% and specificity of 56%.1
Use CRB65 score to help guide and review1:
Each scores 1: Confusion (Abbreviated Mental
Test score <8);
Respiratory rate >30/min; Age >65;
BP systolic <90 or diastolic ≤ 60
Score 0: suitable for home treatment;
Score 1-2: hospital assessment or admission
Score 3-4: urgent hospital admission
Give immediate IM Benzylpenicillin or Amoxicillin 1g po (IM Cefotaxime
in non-severe penicillin allergy) if delayed admission/life threatening.1,2D
When to investigate For patients managed in the community microbiological investigations are not recommended routinely.1 Examination of sputum should be
considered for patients who do not respond to empirical antibiotic therapy.1
Treatment choices2
IF CRB65=0:
AmoxicillinA+ 500mg tds for 7 days AND/OR
[ClarithromycinA- 500mg bd for 7 days OR
DoxycyclineD 200 mg stat/100 mg od for 7 days]
If CRB65=1 & AT HOME:
AmoxicillinA+ 500mg – 1g tds AND ClarithromycinA- 500mg bd both for
7-10 days
OR Doxycycline alone 200mg stat then 100mg od for 7-10 days
Some hospital specialists may prescribe high-dose doxycycline 200mg bd for 2 days then 200mg od for 7-10 days.D
Cautions
In elderly patients, the classic symptoms and signs of pneumonia are less likely, and non-specific features – especially confusion – are
more likely.1 In addition, absence of fever is more common compared to younger patients with CAP.1
Aspiration pneumonia is significantly more common in patients who reside in a nursing home or long-term-care facility.4
Do not use ciprofloxacin first line due to poor pneumococcal activity. Reserve all quinolones for proven resistant organisms.2
Evidence
Consider doxycycline, alone or combined with amoxicillin, if infection with Mycoplasma pneumoniae is suspected (most likely in school age
children and young adults with non-severe symptoms if there is a known epidemic).3 Mycoplasma infection is rare in over 65s.2
References
1. BTS. Guidelines for the Management of Community Acquired Pneumonia in Adults: 2009 Update. http://www.brit-thoracic.org.uk/guidelines/pneumonia-guidelines.aspx
3. P RODIGY Community Acquired Pneumonia. http://www.prodigy.clarity.co.uk/chest_infections_adult/management/scenario_community_acquired_pneumonia
(Accessed March 2012)
4. G
arcia-Vidal C et al. Low incidence of multidrug-resistant organisms in patients with healthcare-associated pneumonia requiring hospitalization.
Clin Microbiol Infect 2011; 17: 1659–1665.
page 18
Central Nervous
System
CNS
Central Nervous System Infections – Meningitis or Suspected Meningococcal Disease
When to treat
Transfer all patients to hospital immediately.1 IF time before admission, give IV benzylpenicillin or cefotaxime2,3B+, unless hypersensitive
i.e. history of difficulty breathing, collapse, loss of consciousness, or rash.1B-
Treatment choices
IV or IM Benzylpenicillin:1
Neonate 75mg/kg
Child: 1 month - 1yr: 300mg
Child: 1yr - 9yrs: 600mg
Child: 10-18yrs: 1.2g
Adult: 1.2g
Give IM if vein cannot be found.1
OR
IV or IM Cefotaxime1
Neonate 50mg/kg
Child: 1 month - 12yrs: 50mg/kg (max 1g)
Child: 12-18yrs: 1g
Adult: 1g
If history of immediate hypersensitivity
reaction to penicillins or cephalosporins4
IV Chloramphenicol
Child: 1 month - 18 yrs: 25mg/kg IV
Adult: 25mg/kg IV
Prevention of secondary case of meningitis.5 Only prescribe following advice from Public Health Doctor:
9am - 5pm 0845 055 2022. Out-of-hours contact: 0844 967 0082 (from 1st February 2012).
Cautions
For suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia), give parenteral antibiotics
(intramuscular or intravenous benzylpenicillin) at the earliest opportunity in primary care, but do not delay urgent transfer to hospital to
give the parenteral antibiotics.2
Evidence
The NICE guideline development group recommended benzylpenicillin because it is the most frequently used antibiotic in primary care
and they found no evidence to recommend an alternative antibiotic.1
References
1. M
anagement of Infection Guidance for Primary Care, HPA & BIA, Jan 2012.
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
2. N
ICE. Bacterial meningitis and meningococcal septicaemia. National Collaborating Centre for Women’s and Children’s health 2009. (Clinical Guideline 102)
http://guidance.nice.org.uk/CG102/Guidance
3. S IGN 2008. Management of invasive meningococcal disease in children and young people. Scottish Intercollegiate Guidelines Network. 2008
http://www.sign.ac.uk/guidelines/fulltext/102/index.html
4. BNF-C 2011/12.
5. H
PA 2011 Guidance for public health management of meningococcal disease in the UK.
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/MeningococcalDisease/
page 19
Urinary Tract
Infections
UTI
UTI
Urinary Tract Infections – Uncomplicated UTI in Women
When to treat
Women with severe or ≥ 3 symptoms (frequency, urgency, dysuria, polyuria, suprapubic tenderness, haematuria): treat1B+
Women with mild or ≤ 2 symptoms: perform dipstick on cloudy urine to guide treatment (morning specimen most reliable).1,2
• Positive nitrite indicates probable UTI, if EITHER blood OR leucocytes also positive = 92% positive predictive value1A• Negative nitrite, leucocytes and blood = 76% negative predictive value1AAlthough the probability of UTI is reduced to less than 20% by a negative dipstick test, the evidence suggests that women still derive
symptomatic benefit from antibiotics (NNT=4).3
Non-pregnant women with asymptomatic bacteriuria should not receive antibiotic treatment.3
In women with symptoms of vaginal itch or discharge, explore alternative diagnoses and consider pelvic examination.3
When to
investigate
Do not culture routinely for urinary symptoms in adult women <65 years.2
In sexually active young women, consider Chlamydia trachomatis.2C
Do not send urine for culture in asymptomatic elderly with positive dipsticks; only send urine for culture if two or more signs of infection,
especially dysuria, fever > 38°C or new incontinence.2
Perform culture (mid-stream) if failed antibiotic treatment or persistent symptoms.2
How to respond Single organism ≥ 104 colony forming units (CFU)/mL or ≥ 105 mixed growth with one predominant organism or E. coli or Staphylococcus
to a positive lab saprophyticus ≥ 103 CFU/mL usually indicates UTI in patient with urinary symptoms.
White cells ≥ 104/mL are considered to represent inflammation. In adults ‘no white cells present’ indicates no inflammation & reduces culture
report2
significance. Epithelial cells/mixed growth indicates perineal contamination, reducing significance of culture.
Treatment
choices
First line:1
TrimethoprimB+ 200 mg bd for 3 days1A+ OR
NitrofurantoinB+ 50mg qds4
(or 100mg m/r bd) for 3 days3,4
Cautions
Avoid nitrofurantoin if GFR<60ml/min; risk of peripheral neuropathy; ineffective due to inadequate urine concentrations.5,6 The activity of
nitrofurantoin is reduced with increasing pH; avoid alkalinising agents e.g. potassium citrate.1
Evidence
Three days of treatment with nitrofurantoin has been shown to be effective in non-pregnant adult women with uncomplicated UTI.3 If dysuria
and frequency are present, the probability of UTI is > 90%.3
References
2. HPA. Diagnosis of UTI – Quick Reference Guide for primary care. April 2011. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
3. SIGN UTI 2006 http://www.sign.ac.uk/guidelines/fulltext/88/index.html (Accessed January 2012)
4. PRODIGY Urinary Tract Infection – Lower, Women. http://www.prodigy.clarity.co.uk/urinary_tract_infection_lower_women (Accessed January 2012)
5. BNF 63, March 2012
6. Sachs J et al. Effect of renal function on urinary recovery of orally administered nitrofurantoin. NEJM 1968; 278(19): 1032-1035.
Second line: Perform culture in all treatment failures1B
Amoxicillin resistance is common; only use if susceptible.1B+
Community multi-resistant Extended-spectrum Beta-lactamase (ESBL) E. coli are increasing:
consider nitrofurantoin (or fosfomycin 3g stat on advice of microbiologist).1
page 21
20
Urinary Tract Infections – Lower UTI in Pregnancy
When to treat
Pregnant women with symptomatic UTI should be treated with an antibiotic.1
Asymptomatic bacteriuria detected during pregnancy should be treated with an antibiotic; asymptomatic bacteriuria is associated with
pyelonephritis & premature delivery.1,2
When to
investigate
MSU should be performed routinely at the first antenatal visit.1,2 If bacteriuria is reported, it should be confirmed with a second MSU.1,2 Dipstick
testing is not sufficiently sensitive to be used for screening for bacteriuria in pregnant women.1,2
Given the risks of symptomatic bacteriuria in pregnancy, a urine culture should be performed seven days after completion of antibiotic
treatment as a test of cure.1
How to respond Single organism ≥ 104 colony forming units (CFU)/mL or ≥ 105 mixed growth with one predominant organism or E. coli or Staphylococcus
to a positive lab saprophyticus ≥ 103 CFU/mL usually indicates UTI in patient with urinary symptoms. In adults ‘no white cells present’ indicates no inflammation
& reduces culture significance. Epithelial cells/mixed growth indicates perineal contamination, reducing significance of culture.3
report
Women with bacteriuria confirmed by a second urine culture should be treated and have repeat urine culture at each antenatal visit until delivery.1
Treatment
choices
First line:3 Treat for 7 daysC
Amoxicillin 250mg tds (if known to be susceptible) OR
Nitrofurantoin 50mg qds or 100mg m/r bd OR
Trimethoprim 200mg bd (off-label). Give folic acid if first trimester.
Cautions
The activity of nitrofurantoin is reduced with increasing pH; avoid alkalinising agents e.g. potassium citrate.2
Trimethoprim is a folate antagonist. Folate supplementation during the first trimester reduces the risk of neural tube defects in offspring of
pregnant women treated with trimethoprim.2 In women with normal folate status, who are well nourished, trimethoprim is unlikely to cause
folate deficiency.4 However, it should not be used by women with established folate deficiency or low dietary folate intake, or by women taking
other folate antagonists (e.g. antiepileptic drugs or proguanil).2,3,4
*High-risk drug for Clostridium difficile infection and should be avoided in at-risk patients.
Evidence
Nitrofurantoin has been associated with haemolysis in people with G6PD deficiency. However, the risk seems very small because placental
transfer is so low.2 There is only one reported case of haemolytic anaemia in a newborn whose mother was treated at term with nitrofurantoin.2
The efficacy and safety profiles of nitrofurantoin are supported in a recent large multicentre study undertaken by the World Health Organization
in which 778 pregnant women with asymptomatic bacteriuria were treated with nitrofurantoin [Lumbiganon et al, 2009]. A cure rate of 86%
was achieved with a 7-day course.3
References
3. PRODIGY Asymptomatic bacteriuria and cystitis in women who are pregnant. http://www.prodigy.clarity.co.uk/urinary_tract_infection_lower_women/management/
scenario_asymptomatic_bacteriuria_and_cystitis_in_pregnancy (Accessed January 2012)
4. UK Teratology Information Service. The treatment of infections in pregnancy. (Tel: 0844 892 0909) www.toxbase.org (Accessed January 2012)
Second line:3
Cefalexin* 500mg bd or 250mg qds for 7 daysB-
page 22
Urinary Tract Infections – Lower UTI in Men
When to treat
Conditions like prostatitis, chlamydial infection and epididymitis should be considered in the differential diagnosis of men with acute dysuria
or frequency and appropriate diagnostic tests should be considered.1
In elderly men (over 65 years of age), treatment of asymptomatic bacteriuria does not reduce mortality or significantly reduce symptomatic
episodes.1 Antibiotic treatment significantly increases the risk of adverse events, such as rashes and gastrointestinal symptoms (NNTH 3).1
When to
investigate
A urine sample is recommended because UTI in men is generally regarded as complicated (it results from an anatomic or functional
abnormality).1,2
Send pre-treatment MSU3 C OR if symptoms mild/non-specific, use negative dipstick (both nitrite & leucocytes) to exclude UTI.3,4 C
How to respond
to a positive lab
report
Follow up after 48 hours (or according to the clinical situation) to check response to treatment and the urine culture results.4
Obtaining a clean-catch sample of urine in men is easier than in women and a colony count of ≥103 cfu/ml may be sufficient to diagnose
UTI in a man with signs and symptoms as long as 80% of the growth is of one organism.1
Treatment
choices
First line:3,4
Treat for 7 days3,4 C
TrimethoprimB+ 200 mg bd
OR
NitrofurantoinB+ 50mg qds4 (or 100mg m/r bd)
Cautions
Trimethoprim is not recommended if the man has used it in the past 12 months because use of trimethoprim up to 1 year previously is
associated with increased risk of infection with a resistant organism.1
Avoid nitrofurantoin if GFR<60ml/min; risk of peripheral neuropathy; ineffective due to inadequate urine concentrations.5,6
At least 50% of men with recurrent UTI and over 90% of men with febrile UTI have prostate involvement, which may lead to complications
such as prostatic abscess or chronic bacterial prostatitis.1 (Section 5.7 – Acute Prostatitis).
Evidence
No high quality evidence for the treatment of bacterial UTI in men was identified.1
References
2. HPA. Diagnosis of UTI – Quick Reference Guide for primary care. April 2011.http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
4. PRODIGY Urinary Tract Infection (lower) – Men. http://www.prodigy.clarity.co.uk/urinary_tract_infection_lower_men (Accessed January 2012)
5. BNF 63, March 2012
6. Sachs J et al. Effect of renal function on urinary recovery of orally administered nitrofurantoin. NEJM 1968; 278(19): 1032-1035.
Second line:
Perform culture in all treatment failures3 B
Amoxicillin resistance is common; only use if susceptible.3 B+
Community multi-resistant Extended-spectrum Beta-lactamase (ESBL) E. coli are
increasing: consider nitrofurantoin (or fosfomycin 3g stat plus 2nd 3g dose 3 days
later on advice of microbiologist).3
page 23
Urinary Tract Infections – Catheter-associated UTI
When to treat
Between 2% and 7% of patients with indwelling urethral catheters acquire bacteriuria each day, even with the application of best practice for
insertion and care of the catheter.1 All patients with a long-term indwelling catheter are bacteriuric, often with two or more organisms.1
Treatment of asymptomatic bacteriuria does not reduce mortality or prevent symptomatic episodes and causes harms: increased short-term
frequency of symptomatic infection and re-infection with antimicrobial-resistant organisms.2B+,3
Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely.4B+ Symptoms that may
suggest UTI in patients with catheters include fever, flank or suprapubic discomfort, change in voiding patterns, nausea, vomiting, malaise or confusion.1
When to
Symptomatic catheter-associated UTI (CA-UTI) cannot be differentiated from asymptomatic bacteriuria on the basis of urine analysis with
dipstick tests.1 Dipstick testing should not be used to diagnose UTI in catheterised patients.1
investigate
Urine samples should only be sent for laboratory culture if the patient has clinical sepsis, not because the appearance or smell of the urine
suggests that bacteriuria is present.1
A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed CA-UTI because of the wide spectrum of
potential infecting organisms and the increased likelihood of antimicrobial resistance.5
• If an indwelling catheter has been in place for >2 weeks at the onset of CA-UTI and is still indicated, the catheter should be replaced to
hasten resolution of symptoms and to reduce the risk of subsequent CA-UTI.5 The urine for culture should be obtained from the freshlyplaced catheter prior to the initiation of antimicrobial therapy.5
• In patients with short-term catheterisation, it is recommended that specimens be obtained by sampling through the catheter port using
aseptic technique or, if a port is not present, puncturing the catheter tubing with a needle and syringe.5 Culture specimens should not be
obtained from the drainage bag.
How to respond If urine culture shows that the organism is resistant to the current antibiotic, and:
to a positive lab • If symptoms have not resolved, change to an antibiotic that the organism is sensitive to.
• If symptoms have resolved, consider continuing with the current antibiotic.
report
• If symptoms recur, start treat with an antibiotic shown in the culture to cover the infecting organism.
Upper UTI (fever or loin pain):6
Treatment
Lower UTI:6 Trimethoprim 200 mg bd for 7 days OR
Nitrofurantoin 50mg qds (or 100mg m/r bd) for 7 days
See Pyelonephritis
choices
Cautions
Avoid nitrofurantoin if GFR<60ml/min; risk of peripheral neuropathy; ineffective due to inadequate urine concentrations.7
Evidence
When changing catheters in patients with a long-term indwelling urinary catheter: do not offer antibiotic prophylaxis routinely. Consider
antibiotic prophylaxis for patients with a history of symptomatic UTI after catheter change or who experience trauma during catheterisation.4B
References
3. European Association of Urology. Guidelines on Urological Infections 2011. http://www.uroweb.org/guidelines/online-guidelines/
5. Infectious Diseases Society of America. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guideline
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Comp%20UTI.pdf (Accessed January 2012).
6. PRODIGY Lower UTI with catheter. http://www.prodigy.clarity.co.uk/urinary_tract_infection_lower_women# (Accessed January 2012)
7. BNF 63, March 2012
page 24
Urinary Tract Infections – UTI in Children
When to treat
When to
investigate
How to respond
to a positive lab
report
Treatment
choices
Evidence
References
Consider UTI in any sick child and every young child with unexplained fever.1A+
UTIs in children require prompt treatment to minimise the risk of renal scarring.2
Child < 3 months: refer urgently for assessment1,3 C
Child 3 months - 3 years: send MSU for culture1,3 A+
Child ≥ 3 years: use positive dipstick to indicate antibiotics and send MSU for culture1,3 A+
Delay the decision about treating with an antibiotic until the results of urine culture are available for children who have no specific symptoms
for UTI, and are at intermediate risk for severe illness (and the urine dipstick tests for nitrite and leukocyte esterase are negative) or low-risk
for serious illness.4
Send pre-treatment MSU for all children ≥3 months.5
Imaging: only refer if child <6 months, recurrent or atypical UTI.3,5 C
Whenever possible a specimen of urine should be collected for culture and sensitivity testing before starting antibacterial therapy – clean
catch if possible.1,3
Dipstick: positive nitrite & leucocytes = likely UTI.1,3 Nitrite positive & leucocytes negative, in sample <4hrs old = likely UTI.1,3
Single organism ≥ 104 colony forming units (CFU)/mL indicates UTI; in supra-pubic aspirates any growth is significant.1
White blood cells: In children pyuria may be absent or, in contrast, present due to fever without UTI.1
Routinely review with the culture result (e.g. at around 48 hours) to ensure that the child is responding to treatment, and to reassess the
choice of antibiotic.4
Preventing recurrence
See Children’s BNF for doses First line:2,3,4,5
Second line:5
In accordance with sensitivity • Address dysfunctional elimination
results
syndromes and constipation.3
If susceptible: AmoxicillinA • Encourage children3 to drink an
Lower UTI: Uncomplicated lower TrimethoprimA OR
adequate amount.
UTI in children > 3 months can be NitrofurantoinA- tabs (not m/r) OR
• Emphasize the importance of not
or suspension (note: expensive)
CefalexinC
treated for 3 days3A+
delaying voiding.3
Upper UTI: consider hospital Co-amoxiclavA+ for 7-10 daysA+ CefiximeA for 7-10 days A+
4
admission
Prophylactic antibiotics for recurrent symptomatic UTI: Although it is effective in reducing the number of positive urine cultures, there is no
benefit through a reduction in the number of symptomatic infections or new renal parenchymal defects.3 It is inconvenient for the patient,
compliance is poor, it carries the risks associated with any medication and patients tend to become colonised with resistant organisms.3
2. BNF for children 2011-12. http://bnfc.org/bnfc/index.htm
3. NICE. Urinary Tract Infection in Children 2007. (Clinical Guideline 54). http://www.nice.org.uk/CG54
4. PRODIGY Urinary Tract Infection – Children. http://www.prodigy.clarity.co.uk/urinary_tract_infection_children (Accessed January 2012).
page 25
Urinary Tract Infections – Recurrent UTI in Women – Prophylaxis
When to treat
Recurrent UTI is defined as ≥ 3UTIs per year.1
If cystitis is related to sexual intercourse, advise: Using a different contraceptive method if a diaphragm is being used; voiding soon after
intercourse; using a lubricant if symptoms could be due to mild trauma rather than infection.2
• Continuous or postcoital antimicrobial prophylaxis should be considered to prevent recurrent uncomplicated cystitis in women in whom
non-antimicrobial measures have been unsuccessful.3
• In appropriate women with recurrent uncomplicated cystitis, self-diagnosis and self-treatment with a short course ‘stand-by’ regimen of an
antimicrobial agent should be considered.1,2,3B+
When to
investigate
Seeking specialist advice before starting continuous antibiotic prophylaxis is recommended pragmatically to decide whether the woman
needs investigation to exclude an underlying cause.2
How to respond
to a positive lab
report
Before any prophylaxis regimen is initiated, eradication of a previous UTI should be confirmed by a negative urine culture 1-2 weeks after
treatment.3 The choice of antibiotics should be based upon the identification and susceptibility pattern of the organism that causes the UTI
and the patient’s history of drug allergies.3
Treatment
choices
Non-antibiotic treatment:2
• Cranberry products reduce the recurrence
rate of cystitis, and are available from shops
(not on NHS).
• Cranberry products should not be taken if
warfarin is being used.
• High strength capsules (containing at
least 200 mg of cranberry extract) are
recommended because they may be more
effective and acceptable than cranberry juice.
Cautions
Monitor patients on long term nitrofurantoin for signs of pulmonary fibrosis.4 Avoid nitrofurantoin if GFR<60ml/min; risk of peripheral
neuropathy; ineffective due to inadequate urine concentrations.4
Evidence
Nightly prophylaxis: pooled data from 10 RCTs of poor methodological quality calculated a Relative Risk of having one microbiological
recurrence was 0.21 (95% CI 0.13 to 0.34), favouring antibiotic and the NNT was 1.85 over 6–12 months. But adverse effects do occur and
30% of women did not adhere to treatment.1
References
2. PRODIGY Urinary Tract Infection (lower) – Women – Recurrent cystitis. http://www.prodigy.clarity.co.uk/urinary_tract_infection_lower_women
4. BNF 63, March 2012
For women in whom episodes of
infection are associated with sexual
intercourse:1B+
Nitrofurantoin 50mg-100mg stat postcoital dose1,3 to be taken within 2 hours of
intercourse2 (off-label use)
OR
Trimethoprim 100mg stat post-coital dose1,2
to be taken within 2 hours of intercourse2
(off-label use)
Long-term low dose prophylaxis
taken at bedtime:1A+
A 6-month trial is recommended, as this
reflects the duration of most trials of
prophylactic antibiotics.2 Information on
long-term follow up is lacking.2
Nitrofurantoin 50-100mg at night1,3
OR
Trimethoprim 100mg at night1,3
page 26
Urinary Tract Infections – Acute Pyelonephritis (Upper UTI)
When to treat
Upper urinary tract infection is defined as: evidence of urinary tract infection with symptoms suggestive of pyelonephritis (loin pain, flank
tenderness, fever, rigors or other manifestations of systemic inflammatory response).1 Upper urinary tract infection can be accompanied by
bacteraemia, making it a life threatening infection.1
Admit to hospital people who:2
• Are significantly dehydrated or who are unable to take oral fluids and medications.
• Have signs of sepsis, including:
• A temperature greater than 38°C or less than 36°C, and
• Marked signs of illness (such as impaired level of consciousness, perfuse sweating, rigors, pallor, significantly reduced mobility), or
• Significant tachycardia, hypotension, or breathlessness.
• Are pregnant and pyrexial.
• Are frail, elderly residents in care homes who have recently been hospitalised or who have had recurrent UTI.
• Fail to improve significantly within 24 hours of starting antibiotics.
When to
investigate1
Dipstick test the urine for leucocyte esterase and nitrite for evidence of a UTI.2
• If the nitrite test is positive, with or without a positive leucocyte esterase test, a UTI is highly (90%) likely.
• If the leucocyte esterase test alone is positive, a UTI is moderately (50%) likely.
• If both dipstick tests are negative, a UTI is unlikely (5%). Consider and exclude other causes of loin pain and/or fever including: pelvic
inflammatory disease; appendicitis; renal calculi.
If hospital admission not needed, send MSU for culture & sensitivities and start antibiotics.3C
How to respond
to a positive lab
report
Single organism ≥ 104 colony forming units (CFU)/mL or ≥ 105 mixed growth with one predominant organism or E. coli or Staphylococcus
saprophyticus ≥ 103 CFU/mL usually indicates UTI in patient with urinary symptoms.3 Review culture and sensitivity results when they become
available, and change the antibiotic if indicated.2
Treatment
choices
First line:1,3,4
*CiprofloxacinA- 500mg bd for 7 daysA
Cautions
*High-risk drugs for Clostridium difficile infection but benefits considered to outweigh risks in acute pyelonephritis.3
Nitrofurantoin is an ineffective treatment for upper UTI because it does not achieve effective concentrations in the blood.1
Evidence
One week of treatment with ciprofloxacin is as effective as two weeks treatment with co-trimoxazole.1 Evidence about the effectiveness of
less than two weeks treatment with co-amoxiclav is lacking.1
References
1. SIGN UTI 2006 http://www.sign.ac.uk/guidelines/fulltext/88/index.html (accessed January 2012)
2. PRODIGY Pyelonephritis – acute. http://www.prodigy.clarity.co.uk/pyelonephritis_acute (accessed March 2012)
Second line:1,3 (if no penicillin allergy)
*Co-amoxiclavC 625mg tds for 14 daysC
page 27
GTI
Genital Tract
Infections
GTI
Genital Tract Infections – Criteria for referring patients to specialist care
Patient risk factors
Refer patents with the following risk factors for STIs to GUM/Sexual Health Services clinic or general practices with level 2 or 3 expertise
in GUM/Sexual Health Services:1,2
• <25yrs
• no condom use
• recent (<12mth) or frequent change of sexual partner
• previous STI
• symptomatic partner
Diseases
• Syphilis – always refer to GUM/Sexual Health Services
• Gonorrhoea – always refer to GUM/Sexual Health Services
• Genital Herpes – Treat on suspicion and refer to GUM/Sexual Health Services
Evidence
See Health Protection Agency and British Infection Association Quick Reference Guide to Management and Laboratory Diagnosis of
Abdominal Vaginal Discharge for useful flowchart.3
References
1. RCGP & BASHH Guidance: Sexually Transmitted Infections in Primary Care (2006) http://www.bashh.org/guidelines (Accessed January 2012)
2. National Chlamydia Screening Programme http://www.chlamydiascreening.nhs.uk/ps/index.html (Accessed January 2012)
3. H
PA / BIA: Quick Reference Guide for Primary Care management of Abnormal Vaginal Discharge in Women (amended 26.09.11)
page 29
Genital Tract Infections – Vulvo Vaginal Candidiasis
When to treat
Symptoms suggestive of episodic vulvovaginal candidiasis include external dysuria, vulval pruritus, swelling or redness.
Signs include vulval oedema, fissures, excoriation, or thick curdy discharge.1 The vaginal pH is usually normal (<4.5). Treatment on the
basis of symptoms alone is common clinical practice but results in the over-treatment of a large number of women.1
There is no evidence to support the treatment of asymptomatic male sexual partners in either episodic or recurrent vulvovaginal
candidiasis.2A
When to investigate Microscopy and culture are not routinely done on women with features of typical acute uncomplicated vulvovaginal candidiasis.3,4
Microscopy and speciated fungal culture of vaginal secretions to identify yeasts is recommended for: supporting the diagnosis when this
is uncertain; severe vulvovaginal candidiasis; treatment failure; recurrent vulvovaginal candidiasis.3 Request ‘Fungal speciation to nonalbicans Candida species’ when treatment fails.3
How to respond to
a positive lab result
Advise the woman to return if symptoms have not resolved within 7–14 days.3 Refer, or seek specialist advice, if: symptoms are not
improving and treatment failure is unexplained; treatment fails again; if diagnosis is unclear.3
General advice
Routine recommendation of use of vulval moisturisers (such as aqueous cream or Epaderm ointment) as soap substitute and regular skin
conditioner (permission may need to be given to the patient that this does not constitute ‘internal use’).2 Avoid tight fitting synthetic
clothing.2 Avoid local irritants e.g. perfumed products.2
Treatment choices
First line non-pregnant 5
ClotrimazoleA+ 10% Vaginal Cream (5g) stat
OR ClotrimazoleA+ 500mg pessary stat at night
OR FluconazoleA+ 150mg orally stat
Cautions
There is evidence from a number of randomized controlled trials that vulval burning and vaginal discharge are more common with
intravaginal imidazoles, whilst nausea, headache, and abdominal pain are more common with oral imidazoles.3
Evidence
No statistically significant differences were observed in clinical cure rates of antifungals administered by the oral or the intravaginal
route. At short-term follow-up, 74% cure was achieved with oral treatment and 73% cure with intra-vaginal treatment
(OR 0.94, 95% CI 0.75 to 1.17).5
References
1. British Association of Sexual Health and HIV 2006. Sexually Transmitted Infections: UK National Screening and Testing Guidelines. http://www.bashh.org/guidelines
2. BASHH 2007. United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis. http://www.bashh.org/guidelines
3. PRODIGY Candida female genital. http://prodigy.clarity.co.uk/candida_female_genital (Accessed January 2012).
4. H
First line pregnant 5
Clotrimazole A+ 100 mg pessary at night for 6 nightsC
OR Miconazole 2% creamA+ 5 g intravaginally bd for 7 days
page 29
30
Genital Tract Infections – Bacterial Vaginosis
When to treat
Treatment is indicated for: symptomatic women (offensive fishy-smelling vaginal discharge, not associated with soreness, itching, or
irritation)A; women undergoing some surgical proceduresA; and some pregnant women.1
Symptomatic pregnant women should be treated in the usual wayB and asymptomatic pregnant women may be considered for
treatment.1 Routine screening and treatment of male partners is not indicated.1,2
When to investigate Examination and further tests may be omitted and empirical treatment for bacterial
vaginosis (BV) started in women with characteristic symptoms of BV if all of the
following apply2:
• The woman is not at high risk of a sexually transmitted infection (STI).
• The woman does not have symptoms of other conditions causing vaginal discharge
(e.g. itch, abdominal pain, abnormal bleeding, dyspareunia, fever).
• The woman is not pregnant, post-natal, post-miscarriage, or post-termination.
• Symptoms have not developed after a gynaecological procedure.
• Symptoms have not recurred soon after treatment for BV or persisted following
treatment for BV.
If empirical treatment is not considered
appropriate, or if the diagnosis is uncertain2:
• Perform a speculum examination.
• If pH paper is available, test the pH of the
vaginal fluid (pH > 4.5 is consistent with a
diagnosis of BV).3
• Take a high vaginal swab (or use a self-taken
low vaginal swab) for Gram staining and to
exclude other causes of vaginal discharge.
General advice
Advise patients to avoid vaginal douching, use of shower gel, and use of antiseptic agents or shampoo in the bath.1C
Treatment choices
First Line:1,2,4
Metronidazole 400mg oral bd for 5-7 daysA+, (preferred over 2g stat for efficacy and also in pregnancy)5
OR Metronidazole 2g stat A+ (consider suspension formulation at night for better tolerability; avoid 2g dose in pregnancy)5
OR Metronidazole 0.75% vaginal gel 5g applicatorful at night for 5 days A+
OR Clindamycin 2% vaginal cream, 5g applicatorful at night for 7 days A+
Cautions
Clindamycin cream weakens condoms-advise against use during treatment.1
Evidence
All treatments have been shown to have cure rates of 70-80%.1A 7 day course of oral metronidazole is slightly more effective than 2g stat.1A
Topical treatment gives similar cure ratesA+ but is more expensive.
References
1. BASHH: National Guideline For The Management Of Bacterial Vaginosis (2006) http://www.bashh.org/guidelines (Accessed January 2012)
2. PRODIGY Bacterial Vaginosis http://prodigy.clarity.co.uk/bacterial_vaginosis
3. H
5. UK Teratology Information Service. Use of metronidazole in pregnancy. 2008. (Tel: 0844 892 0909) www.toxbase.org (Accessed January 2012)
page 31
Genital Tract Infections – Chlamydia Trachomatis
When to treat
In people with signs or symptoms strongly suggestive of Chlamydia, start treatment without waiting for laboratory confirmation (after
testing for other sexually transmitted infections as appropriate).1 In the absence of treatment, 10-40% of infected women will develop
pelvic inflammatory disease (PID).2
When to investigate Test for Chlamydia if patients are sexually active with symptoms and signs suggesting Chlamydia.1
Opportunistically screen all aged 15-25yrs.3,4
How to respond to
Treat partners and refer to GUM service.3B+
Positive confirmed reactive nucleic acid amplification technique (NAAT) test. Note: In high-risk populations, tests are not confirmed with
culture. Beware of false positive test results in low-risk populations.D Patients with reactive unconfirmed NAAT test results should also be
offered treatment.2
General advice
Patients should be advised to avoid sexual intercourse (including oral sex) until they and their partner(s) have completed treatment (or
wait 7 days if treated with azithromycin).2
Treatment choices
First line: (non-pregnant)1,2,3
Azithromycin 1g statA+ OR
Doxycycline 100mg bd for 7 daysA+
Cautions
Refer all pregnant patients to GUM/Sexual Health Services.1,2
Pregnancy or breastfeeding: azithromycin is the most effective option.3A+
Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment.3C
Evidence
NAATs are more sensitive and specific (90-95%) than enzyme immunoassays (EIAs) (40-70%).
Comparative studies of doxycycline and azithromycin have shown similar efficacy at 2-5 week follow-up, with >95% being Chlamydianegative on retesting.2 However, there is evidence to suggest that with longer follow-up >10% will be positive on retesting (NAATs may
remain positive for up to 5 weeks, even if treatment has been successful).2
Erythromycin and amoxicillin are less effective than doxycycline or azithromycin.1,2,3
References
1. PRODIGY Chlamydia – uncomplicated genital. http://prodigy.clarity.co.uk/chlamydia_uncomplicated_genital (Accessed January 2012).
2. BASHH Management of Chlamydia trachomatis genital tract infection [2006]. http://www.bashh.org/guidelines
4. British Association of Sexual Health and HIV 2006. Sexually Transmitted Infections: UK National Screening and Testing Guidelines. http://www.bashh.org/guidelines
5. UK Teratology Information Service. The treatment of infections in pregnancy. (Tel: 0844 892 0909) www.toxbase.org (Accessed January 2012)
6. BNF 63, March 2012
First line: Pregnant or breastfeeding1,2,3,5
AzithromycinA+ 1g (off-label use) stat
OR ErythromycinA+ 500mg bd for 14 days6
OR AmoxicillinA+ 500mg tds for 7 days
page 31
32
Genital Tract Infections – Trichomoniasis
When to treat
Treat only laboratory confirmed diagnosis.1 Sexual partner(s) should be treated simultaneously.2
Refer to GUM/Sexual Health Services clinic.3
When to investigate All symptomatic patients.4 Yellow, green frothy discharge. Fishy/offensive odour +/- pruritis, vaginitis, dysuria.5
Screening of asymptomatic patients is not recommended.4
How to respond to
Screening for co-existent sexually transmitted infections should be undertaken in both men and women.2
General advice
Patients should be advised to avoid sexual intercourse (including oral sex) until they and their partner(s) have completed treatment and
follow-up.2
Treatment choices
First line:
MetronidazoleA+ 400mg bd for 5-7days3
OR
Metronidazole 2g stat3A+
(consider suspension formulation at night for better tolerabilityD;
avoid 2g dose in pregnancy/breastfeeding3)
Cautions
The single dose has the advantage of improved compliance and being cheaper; however there is some evidence to suggest that the failure
rate is higher with single dose, especially if partners are not treated concurrently.2
If failure to eradicate T. vaginalis, consider tinidazole and check serum Zinc levels.6
Evidence
Treating partners does not reduce relapse.5B+
Most strains of T. vaginalis are highly susceptible to metronidazole and related drugs (approx. 95% cure rate). There is a spontaneous cure
rate in the order of 20-25%.2
References
1. PRODIGY – Trichomoniasis http://prodigy.clarity.co.uk/trichomoniasis (Accessed February 2012)
2. BASHH United Kingdom National Guideline on the Management of Trichomonas vaginalis 2007. http://www.bashh.org/guidelines
4. BASHH United Kingdom National Screening Guidelines 2006
5. HPA 2011 Management and diagnosis of abnormal vaginal discharge. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
6. Johns Hopkins Antibiotic Guide - Trichomonas www.hopkinsguides.com (Accessed February 2012)
Symptomatic relief if metronidazole declined (not cure):3
Clotrimazole pessaryB+ 100mg each night for 6 nights
page 33
Genital Tract Infections – Pelvic Inflammatory Disease (PID)
When to treat
Signs include: Lower abdominal tenderness which is usually bilateral; adnexal tenderness on bimanual vaginal examination; cervical
motion tenderness on bimanual vaginal examination; fever (>38°C).1 Delaying treatment may increase the risk of long term sequelae
such as ectopic pregnancy, infertility and pelvic pain.1 Because of this, and the lack of definitive diagnostic criteria, a low threshold for
empiric treatment of PID is recommended.1
Start treatment and refer woman & contacts to GUM service.2
When to investigate Always culture for gonorrhoea & Chlamydia as positive result supports PID diagnosis.1 However, a negative result does not exclude PID.1
How to respond to a All patients should be offered a pregnancy test when required to exclude pregnancy.1
Refer woman & contacts to GUM service to screen for sexually transmitted infections.2
positive lab result
BASHH Patient information leaflet: http://www.bashh.org/documents/3633
General advice
Rest is advised for those with severe disease.1C Appropriate analgesia should be provided.1C Patients should be advised to avoid
unprotected intercourse until they, and their partner(s), have completed treatment and follow-up.1C
Treatment choices3
If low risk of Gonococcal infection B+
Metronidazole 400mg bd
PLUS:
[Doxycycline1 100mg bd OR Ofloxacin 400mg bd B+]
All for 14 days
Cautions
PID in pregnancy requires parenteral treatment – refer to specialist.1
Ceftriaxone is supplied as a powder which needs to be reconstituted with lidocaine solution. To reconstitute, mix the contents of a 1g
vial with 3.5mL of 1% lidocaine injection BP: half (2mL) of the resulting solution provides 500mg ceftriaxone. It should be given by deep
intramuscular injection.4
Metronidazole is included in some regimens to improve coverage for anaerobic bacteria.1 Anaerobes are of relatively greater importance
in patients with severe PID and metronidazole may be discontinued in those patients with mild or moderate PID who are unable to
tolerate it.1
Evidence
28% of gonorrhoea isolates resistant to quinolones.3B+
References
1. BASHH. UK National Guideline for the Management of Pelvic Inflammatory Disease 2011. http://www.bashh.org/guidelines
2. PRODIGY – Pelvic inflammatory disease http://prodigy.clarity.co.uk/pelvic_inflammatory_disease (Accessed February 2012)
4. Electronic Medicines Compendium – Ceftriaxone Wockhardt 1g. www.medicines.org.uk (Accessed February 2012)
If high risk of GC B+ (partner has it, severe symptoms, sex abroad)
Ceftriaxone 500mg IM statC (seek expert advice if history of severe
penicillin allergy)
PLUS:
Metronidazole 400mg PO bd for 14 days
PLUS:
Doxycycline 100mg bd for 14 days
page 34
Genital Tract Infections – Acute Prostatitis
When to treat
Acute prostatitis should be suspected in a man who presents with a feverish illness of sudden onset; irritative urinary voiding symptoms or
acute urinary retention; perineal or suprapubic pain; exquisitely tender prostate on rectal examination.1
Empirical therapy should be started immediately after urine cultures have been obtained.
When to investigate All patients >35 years need mid-stream urine sample for dipstick testing and culture for bacteria and antibiotic sensitivity.1
(An STI is much more likely in men <35 years. Send first-catch urine for NAATs).2
Admit to hospital if the man is unable to take oral antibiotics, has acute urinary retention or is severely ill.1
Refer urgently if the man has a pre-existing urological condition and consider urgent referral if the man has diabetes or is
immunocompromised.1
How to respond to
Reassess after 24-48 hours:
Review the culture results and ensure that an appropriate antibiotic is being used.1
If there is deterioration or failure to respond to oral therapy, urgent admission and parenteral therapy should be arranged;2
prostatic abscess may need to be excluded or treated.1
Treatment of sexual partners is not required.3
General advice
Adequate hydration should be maintained, rest encouraged and analgesics such as non-steroidal anti-inflammatory drugs if required.3
Most men treated appropriately for acute prostatitis will recover completely within 2 weeks (but treatment should be continued for at
least a further 2 weeks).1
Following recovery, refer for investigation to exclude structural abnormality of the urinary tract.1
Treatment choices
First line:4
Ciprofloxacin* 500mg bd for 28 daysC
OR Ofloxacin* 200mg bd for 28 days
Cautions
Avoid quinolones in people with a history of tendon disorders related to quinolones, or a history of seizures or conditions that predispose
to seizures. *High-risk drug for Clostridium difficile infection and should be avoided in at-risk patients.
Evidence
Quinolones achieve higher prostate levels than trimethoprim.4
UK guidelines recommend treatment for at least 4 weeks to prevent the development of chronic prostatitis.1
References
1. PRODIGY – Acute prostatitis http://prodigy.clarity.co.uk/prostatitis_acute#367395001 (Accessed February 2012)
2. BASHH Management of Chlamydia trachomatis genital tract infection [2006]. http://www.bashh.org/guidelines
3. British Association of Sexual Health and HIV 2008 United Kingdom National guideline for the management of prostatitis. http://www.bashh.org/guidelines
Second line or If allergic to quinolones:4
Co-trimoxazole 960mg bd for 28 days
page 35
Genital Tract Infections – Balanitis
When to treat
When infection is suspected or where symptoms are troublesome or do not resolve with good hygiene.
When to investigate A sub-preputial swab is not necessary to make a diagnosis, but can be useful for identifying the underlying cause. Take a sub-preputial
swab if balanitis is severe, recurrent or persists despite treatment.
Check blood glucose levels or urine for glycosuria if balanitis is severe, persistent, or recurrent (especially if Candidal balanitis is present).
Only swab for Gardnerella-associated balanitis if this is suspected clinically.
If penile cancer is suspected, refer urgently to genitourinary medicine (GUM) or urology.
If ulceration, urethritis or inguinal lymphadenopathy are present refer to GUM.
If balanitis is recurrent and associated with inability to retract the foreskin refer to urology.2 If balanitis is recurrent and no underlying
cause can be identified, or balanitis persists despite treatment, refer to GUM or urology, depending on the most likely underlying cause.
How to respond to
If symptoms are worsening or do not start to improve within 7 days, advise patient to stop hydrocortisone, if prescribed, and take a
sub-preputial swab (if not already done) to exclude or confirm a fungal or bacterial infection, and adjust treatment (if indicated), or seek
specialist advice.2
Screening should be offered to partners where a sexually transmissible agent is found.1
General advice2
Advise daily cleaning under the foreskin with lukewarm water, followed by gentle drying. Soap or other irritants should not be used on the
genitalia. Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
Treatment choices
For suspected non-specific dermatitis, with or without
candidal colonization:2
Prescribe Clotrimazole 1% or Miconazole 2% cream bd until
symptoms settle
OR oral Fluconazole 150mg stat.
If suspected / confirmed Garnerella-associated:2
Metronidazole 400mg bd for 7 days
If suspected / confirmed Streptococcal balanitis:2
Amoxicillin 500mg tds for 7 days OR if penicillin allergic:
Clarithromycin 250mg bd for 7 days.
If inflammation is causing discomfort consider prescribing Hydrocortisone 1% cream or ointment for up to 14 days in addition to
treatment.2
Cautions
Advise about effect on condoms if creams are being applied.1
Evidence
Oral fluconazole was preferred to topical treatment by approximately 80% of men.2 Testing and treating partners who have a proven
candidal or Gardnerella infection will prevent reinfection and recurrent balanitis.2
References
1. British Association of Sexual Health and HIV 2008. UK National Guideline on the Management of Balanoposthitis http://www.bashh.org/guidelines
2. PRODIGY – Balanitis 2009 http://prodigy.clarity.co.uk/balanitis (Accessed February 2012)
page 36
Genital Tract Infections – Epididymo-Orchitis
When to treat
Have a very low threshold for admitting immediately to exclude testicular torsion.1 Consider other causes, such as mumps orchitis (may be
parotid swelling), Behçet’s syndrome (if recurrent epididymitis), tuberculosis, and amiodarone.1
If symptoms are severe or the man or boy is very unwell, consider admitting to hospital, particularly if he has diabetes or is
immunocompromised.1
Ideally refer for same-day or next-day assessment by a sexual health specialist.1 If this is not possible: Obtain a mid-steam urine for
dipstick, microscopy, and culture and test for sexually transmitted infections.1 Empirical therapy should be given to all patients with
epididymo-orchitis before laboratory results are available.2
When to investigate All patients with sexually transmitted epididymo-orchitis should be screened for other sexually transmitted infections.2
If a urinary tract infection is confirmed, refer to a urologist to investigate for an underlying structural abnormality or urinary tract obstruction.1
How to respond to a Tailor treatment according to culture and sensitivity results.
positive lab result
If the patient was gonorrhoea positive, a test of cure should be performed at least 72 hours after completion of antibiotics.2
General advice
Bed rest, scrotal elevation (such as with supportive underwear), and analgesia.1
If symptoms worsen, or do not begin to improve within 3 days, return for reassessment.1
Treatment choices
If sexually transmitted organism related, including
gonorrhoea:3
Ceftriaxone* 500mg stat IM PLUS
Doxycycline 100mg bd for 10-14 days
No intercourse until review. Notify partner.
Most probably due to chlamydia or other non-gonococcal
organism (no risk factors for gonorrhoea) consider:3
Doxycycline 100mg bd for 10-14 days OR
Ofloxacin* 200mg bd for 14 days
No intercourse until review. Notify partner
All causes, but patient is allergic to tetracyclines
and/or cephalosporins:2
Ofloxacin* 200mg bd for 14 days
If due to an enteric organism (for example, Escherichia coli):3
Ofloxacin* 200mg bd for 14 days OR
Ciprofloxacin* 500mg bd 10 days
Cautions
Avoid quinolones in people with a history of tendon disorders related to quinolones, or a history of seizures or conditions that predispose
to seizures.1 *High-risk drug for Clostridium difficile infection and should be avoided in at-risk patients.
Evidence
Cefixime 400mg oral as a single dose may be an alternative to ceftriaxone where IM route is contraindicated or refused.4
Observations in Asia have raised concern over the adequacy of 400mg cefixime for the treatment of genital gonorrhoea.4
References
1. PRODIGY – Scrotal swellings - management http://prodigy.clarity.co.uk/scrotal_swellings/management/scenario_epididymo_orchitis#-404534 Accessed Feb 2012
2. British Association of Sexual Health and HIV 2010. United Kingdom national guideline for the management of epididymo-orchitis. http://www.bashh.org/guidelines
3. British Association of Sexual Health and HIV 2011. Clinical care pathway for management of epididymo-orchitis http://www.bashh.org/guidelines
4. British Association of Sexual Health and HIV 2011. UK National Guideline for the Management of Gonorrhoea in Adults http://www.bashh.org/guidelines
page 37
G-iI
GII
Gastro-intestinal
Infections
Gastro-intestinal infections – Eradication of Helicobacter pylori
When to treat
The presence of H. pylori should be confirmed before starting eradication therapy.1
Eradication is beneficial in duodenal ulcer (DU), gastric ulcer (GU) and low grade MALT lymphoma.2 Patients with non-ulcer dyspepsia (NUD)
testing positive for H. pylori should be offered eradication therapy as it may improve symptoms.3 In chronic NSAID user without ulcer history,
HP eradication will reduce the risk of peptic ulcers and/or bleeding but will not remove all risk.4 Do not offer eradication for GORD.2
Urgently refer patients >55 with new, unexplained and persistent recent-onset dyspepsia for endoscopy.4
When to investigate Test eligible patients (see above) using a urea breath test, a stool antigen test or lab serology testing.5
The urea breath test is preferred in patients who have undergone previous H. pylori eradication therapy.5
Stop PPI use 14 days prior to breath or stool testing. Withhold breath/stool testing for 28 days after antibiotic treatment.5
DU/GU relapse: retest for H. pylori using breath or stool test OR consider endoscopy for culture & susceptibility.2C
NUD relapse: Do not retest, offer PPI or H2RA.2
Patients with complicated peptic ulcer or MALT lymphoma should be retested (using breath test) 4 weeks after treatment.4
Refer for endoscopy culture and sensitivity testing: Patients who have had metronidazole & clarithromycin for any infection & are allergic
to amoxicillin or tetracycline; patients who have received two courses of eradication and still test positive.4
Seek microbiology or gastroenterology advice for third line options.4
Treatment choices
Do not use clarithromycin or metronidazole if used in the last year for any infection2
First choice: All for 7 days2A+
PPI bd (use cheapest)
PLUS: Clarithromycin 500mg bd and
Amoxicillin 1g bd
OR
Clarithromycin 250mg bd and
Metronidazole 400mg bd
Alternative regimen (Relapse or MALToma): All for 14 days2C
PPI bd
PLUS: Tripotassium dicitratobismuthate 120mg qds
PLUS:2 unused antibiotics from the following:
Amoxicillin 1g bd
Metronidazole 400mg tds
Tetracycline 500mg qds
Cautions
There is usually no need to continue PPI/H2RA unless large ulcer, haemorrhage or perforation – continue for 3 weeks.1
Evidence
Helicobacter test & treat strategies will benefit patients with ulcer disease, 8% of patients with functional dyspepsia, and reduce future
risk of ulcer disease, gastric cancer and risks of long-term PPIs.4 For NUD the NNT is 14 for symptom relief.2A+
References
1. BNF 63, March 2012
3. NICE. Dyspepsia 2005. (Clinical guideline 17) http://guidance.nice.org.uk/CG17/
4. HPA 2008 Helicobacter pylori Quick reference guide http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
5. PRODIGY – Proven peptic ulcer http://www.prodigy.clarity.co.uk/dyspepsia_proven_peptic_ulcer#323888001 (Accessed March 2012)
page 39
Gastro-intestinal infections – Infectious Diarrhoea
When to treat
Definition of acute diarrhoea: 3 or more episodes a day, <14d and sample takes shape of pot.1
Empirical treatment for patients well enough to be managed in primary care is not usually recommended because the majority of
illnesses seen in the community do not have an identifiable bacterial cause.2
If Campylobacter is strongly suspected as the cause of diarrhoea (e.g. undercooked meat and abdominal pain), consider empirical
treatment with clarithromycin if treating early.2
Urgently refer all previously healthy children with acute painful, bloody diarrhoea or confirmed E. coli O157.1
When to investigate Send a stool specimen for culture and sensitivity if:
• systemically unwell; blood or pus in the stool;
• if necessary to exclude other pathologies;
• immunocompromised;
• diarrhoea occurs after high risk foreign travel (also request tests for ova, cysts, and parasites);
• recent antibiotics or hospitalisation (also request C. difficile);
• diarrhoea is persistent (e.g. >1week).3
If the diarrhoea has stopped, culture is rarely indicated, as recovery of the pathogen is unlikely.1
Consider blood tests if infection and other causes of acute diarrhoea excluded and a chronic cause is suspected.3
Consult local HPU if: Suspected public health hazard; outbreaks of diarrhoea in the family or community; infected with certain organisms
(e.g. E. coli O157) where there may be serious clinical sequelae to an infection.3
How to respond to
Most patients in whom pathogens are detected will NOT require specific treatment unless systemically unwell or treatment is advised by
a positive lab result1 a microbiologist or consultant in communicable disease control.
Campylobacter: Antibiotic therapy has little effect on duration of symptoms unless given very early in illness course.
Giardia lamblia and Entamoeba histolytica should be treated according to sensitivity results.
Unless symptoms persist, Blastocystis and Dientamoeba fragilis do not usually require treatment if otherwise healthy.
C.difficile: See C.difficile recommendations.
Treatment choices
Fluid replacement is essential.
If systemically unwell and campylobacter suspected consider Clarithromycin 250–500 mg bd for 5–7days if treated early.2C
Evidence
There are no routine methods for detecting enterotoxigenic E. coli, the commonest cause of traveller’s diarrhoea.1
Quinolones are not recommended because there is increasing resistance in Campylobacter to quinolones.2
References
1. HPA 2010 Infectious diarrhoea Quick reference guide for primary care http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
3. PRODIGY – Diarrhoea – adults http://www.prodigy.clarity.co.uk/diarrhoea_adults_assessment (Accessed March 2012)
page 40
Gastro-intestinal infections – Diverticulitis
When to treat1
Antibiotic treatment is recommended for the routine management of diverticulitis, either at home or as an inpatient.
People with mild, uncomplicated diverticulitis can be managed at home with paracetamol, clear fluids, and antibiotics.
Arrange admission for people with diverticulitis when:
• pain cannot be managed with paracetamol;
• hydration cannot be easily maintained with oral fluids;
• oral antibiotics cannot be tolerated;
• the person is frail or has a significant comorbidity that is likely to complicate their recovery (particularly if immunocompromised);
• the person has any of the following suspected complications: rectal bleeding that may require transfusion, perforation and peritonitis,
intra-abdominal abscess, fistula.
When to investigate1 If symptoms persist after 48 hours despite conservative management at home admit patient to hospital.
General advice1
Review within 48 hours, or sooner if symptoms deteriorate. Arrange admission if symptoms persist or deteriorate.
Prescribe paracetamol for pain.
Recommend clear liquids only. Gradually reintroduce solid food as symptoms improve over 2–3 days.
Treatment choices
First choice:
Co-amoxiclav* 625mg tablets tds for 7 days
Evidence
*High-risk for C. difficile infection. Alternative option co-trimoxazole 960mg BD + metronidazole 400mg BD for 7 days.2
Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics have been identified as risk factors for diverticular perforation and
are probably best avoided in the management of people with acute diverticulitis.1
References
1. Prodigy – Diverticular disease http://www.prodigy.clarity.co.uk/diverticular_disease (Accessed March 2012)
2. Jacobs D. Diverticulitis NEJM 2007; 357: 2057-2066
Second choice or if allergic to co-amoxiclav:
Metronidazole 400mg tds for 7 days
PLUS
Ciprofloxacin* 500mg bd for 7 days
page 41
Gastro-intestinal infections – Clostridium difficile Infection
When to treat1
People with mild disease may not require specific C. difficile antibiotic treatment.1
Treat patients with mild-to-moderate C. difficile infection.
If C. difficile positive and the patient has features of severe or life-threatening C. difficile infection, or their condition is rapidly
deteriorating, admit to hospital.
If the condition has improved considerably or resolved without treatment, consider possibility of false-positive result.
Mild: No increased white cell count (WCC) and typically associated with <3 episodes of loose stools/day.
Moderate: Increased WCC (but <15 x 109/L) and typically associated with 3–5 loose stools per day.
Severe: WCC >15 x 109/L, or an acutely increased serum creatinine concentration (>50% above baseline), or a temperature >38.5°C, or
evidence of severe colitis. The number of stools may be a less reliable indicator of severity.
Life-threatening: Signs and symptoms include hypotension, partial or complete ileus, or toxic megacolon.
When to investigate1 Send a stool sample to test for C. difficile toxin if a clinical diagnosis of C. difficile infection is suspected, and the person is symptomatic
with liquid/loose stools (with a consistency that takes the shape of the container).
Document the following details on the request form: Clinical features, recent antibiotic or proton pump inhibitor, or hospital admission,
contact with other affected individuals or outbreak, state whether the test was requested by the HPU or a Consultant in Communicable
Disease Control.
How to respond to
Start treatment. Discontinue therapy with the inciting antibiotic(s) as soon as possible, as this may influence the risk of recurrence.2
a positive lab result Stop unnecessary PPIs. 3B+
Treatment choices
General advice:1
First and second episode:3 Third episode, severe symptoms, or failed response to
Review the person daily and
Metronidazole 400-500mg
metronidazole:
monitor for signs of increasing tds for 10 -14 daysC
Vancomycin oral 125mg qds for 10-14 days3C
Metronidazole should not normally be deemed to have failed until at
severity of disease as they may
least one week of treatment received4
deteriorate very rapidly.
Cautions
If possible, avoid use of antimotility agents as they may obscure symptoms and precipitate toxic megacolon.2
Evidence
70% respond to metronidazole in 5 days; 92% in 14 days.3
Administration of currently available probiotics is not recommended to prevent primary C. difficile.2
The majority of recurrences are due to reinfection rather than relapse and the same antibiotic that had been used initially can be used to
treat a first recurrence.4
1. PRODIGY – Diarrhoea – antibiotic associated. http://www.prodigy.clarity.co.uk/diarrhoea_antibiotic_associated (Accessed March 2012)
References
2. C
ohen S et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the SHEA and the IDSA.
http://www.azdhs.gov/phs/oids/epi/disease/cdif/documents/Cd_ClinicalPracticeGuidelines.pdf
4. DH C. difficile – How to deal with the problem 2009 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093218.pdf
page 42
Gastro-intestinal infections – Travellers’ Diarrhoea (Stand-by or Prophylactic Treatment)
When to treat
Travellers’ diarrhoea is, for most people, a non-serious, self-limiting illness, lasting 3-4 days which will recover without antibiotic
treatment.1 Do not routinely offer prophylactic or standby antibiotics for prevention of travellers’ diarrhoea.1
Prophylactic antibiotics: Consider if the patient is at high risk of diarrhoea and: Is immunocompromised; at high risk of complications
(e.g. Crohn’s disease, UC, colostomy, renal disease, congestive heart failure) or if diarrhoea could severely impact the purpose of a critical trip.1
Standby antibiotics: Only consider for high risk remote areas or for people at high risk of severe illness with travellers’ diarrhoea
(unless eligible for prophylaxis).1
High-risk countries are defined as most of Asia, the Middle-East, Africa, Mexico, Central and Southern America.2
When to investigate Advise travellers to seek medical care if symptoms do not improve within two days (earlier if elderly) or they have a fever or are passing
blood/mucous. Seek immediate attention for children with diarrhoea if dehydration; vomiting; fever or blood.3
General advice
Provide advice on food hygiene and safe drinking water if the person is travelling to locations with low standards of hygiene and sanitation.1
Treatment choices
First line:
Advise the use of oral rehydration salt solution for the management
and prevention of dehydration (particularly for children and infants).1
Loperamide can be considered for travellers in whom frequent
diarrhoea is inconvenient.3
Avoid loperamide in children and patients with inflammatory bowel
disease, a fever or blood in stool.3
Evidence
Azithromycin, bismuth salicylate, loperamide and probiotics are not recommended for prophylaxis.1
Antibiotic treatment is associated with shorter duration of diarrhoea but higher incidence of side-effects.4
The combination of loperamide and an antibiotic in moderate diarrhoea may lead to more rapid improvement compared with either
agent alone.3
References
1. PRODIGY – Diarrhoea – prevention & advice for travellers http://www.prodigy.clarity.co.uk/diarrhoea_prevention_and_advice_for_travellers (Accessed March 2012)
3. Travellers’ diarrhoea. HPA 2011 www.nathnac.org (Accessed March 2012)
4. De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002242.
Prophylaxis: Ciprofloxacin 500mg od (on private Rx) for up to
3 weeks. If contra-indicated seek specialist advice1
Standby: (start if symptoms moderate/severe):
Ciprofloxacin 500mg bd for 3 days (on private Rx)2
OR
If ciprofloxacin contra-indicated or travelling to Thailand/Far East:
Azithromycin 500mg od for 3 days (on private Rx)1
page 42
43
Genital Tract Infections – Threadworms
When to treat1
Treat if threadworms have been seen or their eggs have been detected. All members of the household should be treated at the same time
even if asymptomatic (unless treatment is contraindicated).
When to investigate1 If the diagnosis is uncertain, the adhesive tape test for eggs may be useful – the tape should be examined under a microscope.
If there are frequent recurrences consider seeking advice from a paediatrician or consultant in infectious diseases.
General advice2
In conjunction with treatment, advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower) PLUS wash
sleepwear, bed linen, dust, and vacuum on day one.C
Treatment choices
First line for adults and children aged >6 months:2
Mebendazole 100mg stat chewable tablet (off label if <2yrs)
Repeat in 2 weeks if infestation persists1
Cautions1
Treatment with an anthelmintic is contraindicated in children less than 3 months and women in the first trimester of pregnancy. Women in
the second or third trimester and women who are breastfeeding may prefer not to take an anthelmintic and use hygiene methods.
Evidence1
Neither mebendazole nor piperazine kills eggs, therefore adequate personal and environmental hygiene is essential to prevent
reinfestation from recently swallowed eggs, or eggs already in the environment.
It is generally accepted that mebendazole and piperazine have comparable efficacy (90–100% cure-rate), however mebendazole has few
contraindications and post-marketing surveillance has revealed no serious safety concerns.
References
1. PRODIGY – Threadworms http://www.prodigy.clarity.co.uk/threadworm (Accessed March 2012)
For children aged 3-6 months:1
Piperazine and senna sachet: one level 2.5mL spoonful stat
repeated after 2 weeks
For children aged under 3 months:2
6 weeks strict hygiene to prevent faecal-oral re-infectionC
page 44
S&STI
Skin & Soft Tissue
Infections
Skin & Soft Tissue Infections – Impetigo
When to treat
Although usually self-limiting, treatment is recommended for all cases, as untreated impetigo is highly contagious and there is a risk it
may become generalised.1 Topical antibiotics should be reserved for very localised lesions and oral antibiotics used for extensive, severe or
bullous impetigo.2
Non-bullous impetigo is the most common form. Lesions begin as vesicles or pustules, which rapidly burst and evolve into gold-crusted
plaques. The area around the mouth and nose is most commonly affected.1
Bullous impetigo, which commonly affects neonates, presents with flaccid, fluid-filled vesicles and blisters. These easily burst leaving raw
skin, and eventually form thin, flat, brown-to-golden crusts. Tends to involve the axillae, neck folds, and nappy area. Lesions are usually
painful, are often multiple and spread rapidly.1
When to investigate Skin swabs are not necessary to diagnose impetigo.1
Take a swab (for bacterial identification and sensitivity) if the infection is: very extensive or severe; recurrent (consider nasal swab for
staphylococcal carriage); suspected as being a community outbreak; suspected as being caused by MRSA.1
Advise the person to attend a follow-up appointment if there is no significant improvement after 7 days.1
How to respond to a Review any culture results and ensure that an appropriate antibiotic is being used.
positive lab result
General Advice
Advise that hygiene measures are important to aid healing and stop the infection spreading to other sites on the body and to other
people.1
Treatment choices
Small localised infections:
Fusidic Acid 2% topically tds
for 5 days
Evidence
Topical antibiotics are reserved for treatment of very localised lesions because fusidic acid is an antibiotic that is also used systemically
and there are concerns that widespread use will lead to increased resistance.2 If a topical antibiotic is used, a short course (such as 5 days)
reduces exposure and the risk of resistance.2
There is good evidence that topical fusidic acid and topical mupirocin are at least as effective as oral treatment.3
References
1. PRODIGY – Impetigo http://www.prodigy.clarity.co.uk/impetigo#371003001 (Accessed February 2012)
3. Koning S et al. Interventions for impetigo. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD003261. DOI: 10.1002/14651858.CD003261.pub3
More generalised infections: Second line
If MRSA isolated:
Flucloxacillin 250-500mg qds or if penicillin allergic:
Mupirocin 2% topically tds to
for 7 days
Clarithromycin 250-500mg bd affected area(s) for 5 days
for 7 days
page 45
Skin & Soft Tissue Infections – Eczema
When to treat
If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing.1,2B
Oral antibiotics were not associated with benefit in small trials of eczema without visible signs of infection.1,2,3
However, heavy colonisation of the skin with S. aureus has been reported in people with atopic eczema even when the skin is not
clinically infected, and this may contribute to continuing disease activity.4
In eczema with visible signs of infection, use treatment as in impetigo.1C
If there are localised areas of infection a topical antibiotic in combination with steroid can be considered for no longer than two weeks.
In more generalised infected eczema, use treatment as in impetigoC (i.e. 1st line flucloxacillin) 2,3,4
Refer immediately (same day) to hospital if eczema herpeticum is suspected.3
Signs of eczema herpeticum are:3,4
• areas of rapidly worsening, painful eczema;
• clustered blisters consistent with early-stage cold sores;
• punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter that are uniform in appearance (these may
coalesce to form larger areas of erosion with crusting);
• possible fever, lethargy, or distress.
Refer urgently (within 2 weeks) to a dermatologist if infected eczema has not responded to treatment.3,4
References
1. Management of Infection Guidance for Primary Care, HPA & BIA, Jan 2012 http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
2. B ath-Hextall FJ et al 2010. Interventions to reduce Staphylococcus aureus in the management of atopic eczema:
an updated Cochrane review. British Journal of Dermatology 2010 163, pp12–26
3. PRODIGY – Atopic eczema. http://prodigy.clarity.co.uk/eczema_atopic (Accessed January 2012)
4. NICE 57: Atopic eczema in children. 2007. (Clinical guideline 57) http://guidance.nice.org.uk/CG57/
page 46
Skin & Soft Tissue Infections – Cellulitis
When to treat
Antibiotics should be started without delay as soon as culture specimens (if indicated) have been obtained.1
Cellulitis presents with an acute onset of red, painful, hot, swollen, and tender skin, with possible blister formation.2
Fever, malaise, nausea, shivering and rigors may also occur.2 Differential diagnoses include DVT and varicose eczema.2
When to investigate Consider taking a swab for culture and sensitivity testing if there is a visible portal of entry for bacteria (e.g. an open wound); other
investigations are not usually necessary.2
Consider admission for patients with severe or rapidly deteriorating cellulitis; an uncertain diagnosis with sinister signs or symptoms
(e.g. possible necrotizing fasciitis); severe systemic illness; comorbidities that may complicate or delay healing; facial or periorbital cellulitis;
lymphoedema; or for the very young, elderly or frail people.2
Discuss with microbiologist if there has been exposure to river or sea water.3
How to respond to a Alter treatment in response to culture and sensitivity results of potential pathogens.
positive lab result
Refer people who fail to respond to oral antibiotics or have frequent recurrence of cellulitis, for example more than two episodes at the
same site.2
General advice
Before treatment, draw around the extent of the infection with a permanent marker pen for future comparison.2
Elevation of the affected area speeds improvement by promoting gravity drainage of the oedema/inflammatory substances.4
Treatment choices
First Line:
Flucloxacillin 500mg qds for 7 days C
If penicillin allergic:
Clarithromycin 500mg bd for 7 days OR
Clindamycin* 300-450mg qds C
Mild facial cellulitis:
Co-amoxiclav* 625mg tds for 7 daysC
If slow response continue antibiotics for a further 7 days.
Cautions
Stop clindamycin if diarrhoea occurs.3
Evidence
Topical antibiotics should not be prescribed.5
Swabbing unbroken skin for culture in cases of cellulitis infrequently yields a pathogen.1
References
1. Eron L, Lipinsky B, Low D, Nathwani D, Tice A, Volturo G. Managing skin and soft tissue infections: expert panel recommendations in key decision points JAC 2003; 52: 3-17.
2. PRODIGY – Cellulitis http://prodigy.clarity.co.uk/cellulitis_acute#336611001 (Accessed February 2012)
4. Infectious Diseases Society of America 2005. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections
5. BNF 63, March 2012
page 47
Skin & Soft Tissue Infections – Leg Ulcers
When to treat
Signs of an infected leg ulcer include enlarging ulcer, increased exudate, increased pain, pyrexia, foul odour or cellulitis.1,2,3
See Southern Health Leg Ulcer Guidelines 2009 for full guidance.2 Leg ulcers are always colonised and antibiotics will only promote
healing during active infection.4 If the patient has an active infection, start empirical antibiotics after taking a wound swab for cultures and
sensitivity.4 Potassium permanganate soaks are helpful for malodorous ulcers because they have antiseptic and astringent properties.1
When to
investigate
Arterial or mixed venous/arterial ulcer: refer people to a specialist tissue viability or leg ulcer nurse for further assessment.2
Take a swab for all infected venous leg ulcers before prescribing an antibiotic.1
Leg ulcers should not routinely be swabbed unless there is clinical evidence of infection.4
Use a swab with transport medium and charcoal, to aid survival of fastidious organisms.5 Ideally, clean the ulcer with tap water or saline first, and
remove unhealthy tissue. Then place the swab onto viable tissue displaying signs of infection and rotate gently to pick up any loose material.1
How to respond
to a positive lab
result
Review antibiotics after culture results.4 Seek microbiology advice if colonised with MRSA.5
Swab results determine organisms present and antimicrobial susceptibilities, they do not determine the presence of infection. Group A
ß-haemolytic streptococci can be associated with significant infection and delay healing. Significance of other organisms depends on
presence of the clinical criteria above.5 Inclusion of antibiotic susceptibilities in microbiology report does not necessarily mean an organism is
significant or that it requires antibiotic treatment.5
General advice
Advise patients to keep mobile, elevate legs when immobile, avoid trauma and wear appropriate footwear, use an emollient frequently even
after the ulcer has healed, examine legs regularly for deterioration and wear compression bandages or stockings as advised.1 The use of topical
antibiotics in the management of infected wounds should generally be avoided to minimise the risk of allergy and the emergence of bacterial
resistance.1,3 The use of a topical antiseptic, for example an iodine-based product, may be used as an adjunct to systemic treatment.2,6
Treatment
choices4
First line if evidence of active infection:
Flucloxacillin 500mg qds for 7 days.
If slow response continue for a further 7 daysC
Evidence
There is insufficient evidence to show that any wound dressing (including dressings impregnated with silver) is better than simple
low-adherent dressings for the healing of venous leg ulcers.1 (Seek advice from tissue viability specialist.)
References
1. PRODIGY – Venous Leg Ulcer http://prodigy.clarity.co.uk/leg_ulcer_venous (Accessed February 2012)
2. Southern Health Leg Ulcer Guidelines April 2009. Accessible by hyperlink or search for Southern Health Leg Ulcer Guidelines using internet search engine.
3. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound infection in clinical practice. An international consensus. London: MEP Ltd, 2008. Available
from www.mepltd.co.uk (direct link http://www.woundsinternational.com/pdf/content_31.pdf).
5. HPA 2009 Venous leg ulcers: Infection diagnosis & microbiology investigation. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947339139
6. O
’Meara S, Al-Khurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews. 2010. Issue 1.
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003557/frame.html
If penicillin allergic:
Clarithromycin 500mg bd for 7 days.
If slow response continue for a further 7 daysC
page 48
Skin & Soft Tissue Infections – Diabetic Foot Ulcer
When to treat
When to
investigate
How to respond
to a positive lab
result
General advice
Treatment
choices
Evidence
References
• Antibiotics should not be used for foot ulcers without signs of infection as they do not enhance healing or prevent infection.1
• The clinical diagnosis of foot infection is based on the presence of purulent discharge from an ulcer or signs of inflammation
(i.e. erythema, pain, tenderness, warmth or induration).2 Other signs include foul odour, tissue necrosis and failure of wound healing
despite optimal management.1
• Ideally refer anyone with new diabetic foot infection to a multidisciplinary foot-care team within 24 hours.3 If this is not possible and the
infection is superficial and non–limb-threatening, consider taking swabs then starting empirical antibiotic treatment.3 Mild infections are
those where there is the presence of pus and/or two or more signs of inflammation, but any cellulitis or erythema extends ≤ 2 cm around
the ulcer, infection is limited to the skin or superficial subcutaneous tissues and there are no other local complications or systemic illness.1
• If the infection is severe, refer for urgent inpatient management.3 Patients with any of the following, should be referred for urgent
inpatient management: pink or pale, painful, pulseless foot (indicating critical ischaemia); spreading cellulitis, lymphangitis; crepitus;
systemic symptoms of infection; lack of response of infection to oral antibiotics; suspicion of bone involvement or deep seated infection;
immunocompromised patients or those with poor diabetic control.3,4
Swabs should be taken from the deepest part of the cleaned wound after removal of surface contamination and exudate.3 Ensure that the
person is reviewed within 48 hours.3
Patients should be reassessed 24 to 72 hours after initiating empiric antibiotic therapy to evaluate their response and modify the antibiotic
regimen, if indicated by early culture results.1 Clinical failure of appropriate antibiotics may be due to patient nonadherence, antibiotic
resistance, superinfection, undetected abscess or osteomyelitis or severe tissue ischaemia.1
Care of people with foot ulcers should include re-distribution of foot pressures, investigating vascular insufficiency, optimising glycaemic
control and wound management.5
Advise them to seek urgent medical attention if their symptoms or general condition become worse.3
Elevation of the affected area speeds improvement by promoting gravity drainage of the oedema/inflammatory substances.2
If known to be colonised with MRSA:6
First Line:3 Flucloxacillin 500mg qds for 7 days
Doxycycline 100mg bd for 7 days
If penicillin allergic: Clarithromycin 500mg bd for 7days
Consider adding Metronidazole 400mg tds to cover anaerobes (e.g. if foul odour).4
Consider continuing antibiotics for a further 7 days depending on severity of infection and speed of response to treatment.3
Continue antibiotic therapy until the infection has resolved but not necessarily until a wound has healed.2
Several antibiotics have been shown to be effective, but no single regimen has shown superiority.1
1. Bader M. Diabetic Foot Infection. American Family Physician 2008; 78(1): 71-79.
2. Infectious Diseases Society of America 2005. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections
3. PRODIGY – Diabetes - Type 2 http://prodigy.clarity.co.uk/diabetes_type_2/management/scenario_managing_foot_problems (Accessed February 2012)
4. NICE. Inpatient management of diabetic foot problems 2011. (Clinical guideline 119) http://www.nice.org.uk/CG119 (Accessed February 2012)
5. NICE. Type 2 diabetes foot problems; Prevention and management of foot problems 2004. (Clinical Guideline 10) http://www.nice.org.uk/CG10
page 49
Skin & Soft Tissue Infections – MRSA (meticillin-resistant Staphylococcus aureus)
For MRSA colonisation, prescribe suppression regimen for all patients with positive cultures awaiting elective procedures.1
Consider treating patients with active MRSA infection that has been confirmed by laboratory tests.2 Do not give systemic antibiotics to
patients with minor skin and soft tissue infections or small abscesses (<5 cm). Incise and drain small abscesses without cellulitis and do
not give antibiotic therapy.3
MRSA infections most commonly affect the skin presenting as boils; abscesses; styes; carbuncles; cellulitis; impetigo; wound infections.4
If MRSA enters the blood stream it can affect almost any part of the body.4 Consider admitting people who are MRSA positive if they
have worsening signs of infection (e.g. sepsis, worsening cellulitis, fever, or tachycardia), particularly if they are likely to require parenteral
antibiotic therapy and/or surgical drainage.4
When to investigate Screening for colonisation: GPs or pre-admission clinics should screen all patients awaiting elective admissions.1 Local or national
exceptions may apply. Swabs should be taken from the nose and any skin lesions or wounds.1 The swab should be wiped around the
inside of the patient’s nose for 5 seconds.1
Diagnosing active infection: Swab for pathogens including MRSA, or obtain a specimen if appropriate, if the person has an active
infection and one or more of the following risk factors: elderly or debilitated people with critical or chronic illness; surgical wounds, open
ulcers, intravenous lines, or catheter lines; infected pressure sore; history of MRSA colonisation or infection; recent surgery; recent hospital
discharge; regular nursing home contact or a nursing home resident; recent antibiotic use (especially cephalosporins, fluoroquinolones,
and macrolides); dialysis; permanent urinary catheter.4
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of S. aureus. It can rarely cause severe invasive infections in healthy
people. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene.2C
How to respond to
Suppression of colonisation should take place within the 5 days prior to operation as it may not be successful in the long term.1
a positive lab result For active MRSA infection use antibiotic sensitivities to guide treatment.2 If severe infection or no response to monotherapy after
24-48 hours, seek advice from microbiologist on combination therapy.2
Treatment choices
SUPPRESSION:1 Treat underlying skin conditions (e.g. eczema), remove and/or replace invasive devices and treat skin breaks.
Use both nasal and skin regimens:
Nasal: 2% Mupirocin in paraffin base tds for 5 days A Skin: 4% Chlorhexidine gluconate body-wash/shampoo daily for 5 days
Alternatives: 7.5% povidone iodine or Octenisan daily for 5 days
2
ACTIVE TREATMENT: for MRSA confirmed by lab results:
Doxycycline alone B+ 100mg bd for 7 days OR Clindamycin* aloneB+ 450mg qds for 7 days
Cautions
*High-risk drug for C. difficile infection and should be avoided in at-risk patients. Stop clindamycin if diarrhoea occurs.2
1. Health Protection Agency 2009 MRSA screening and suppression. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947336805 Accessed March 2012
References
When to treat
2. HPA MRSA screening and suppression 2011 http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947336805 (Accessed February 2012)
3. British Society for Antimicrobial Chemotherapy 2008. Guidelines for UK practice for the diagnosis and management of MRSA infections presenting in community
4. PRODIGY – MRSA http://prodigy.clarity.co.uk/mrsa_in_primary_care#344309001 (Accessed February 2012)
page 50
Skin & Soft Tissue Infections – Animal Bite
When to treat
Prescribe prophylactic antibiotics if the wound is less than 48 hours old, at high infection risk and does not require referral to secondary
care.1 High infection risk: cat bites, bites to the hand, foot or face; people aged 50 or over; puncture wounds; wounds requiring surgical
debridement; wounds involving joints, tendons, ligaments or suspected fracture; wounds that have undergone primary closure; people at
risk of serious wound infection (e.g. diabetic, cirrhotic, immunosuppressed, asplenic); people with a prosthetic valve or joint.1
Antibiotics are not usually needed if the wound is more than 48 hours old and there is no sign of local or systemic infection.1
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons, bones, the CNS;
facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds requiring closure; bites that might need
reconstructive surgery; devitalized wounds requiring debridement; bites where the severity is difficult to assess; bites with severe cellulitis;
infections not responding to treatment; people with an increased risk of infection (see above); children with scalp wounds; bites to poorly
vascularised areas.1
Bite wounds suitable for management in primary care do not usually require closure.1
Assess risk of tetanus and rabies.2 If any risk of rabies contact the HPA (tel: 020 8327 6017).
When to investigate Where infection suspected, send a pus or deep wound swab for culture before cleaning the wound and starting antibiotics.1
Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.1 For infected wounds, review at
24 and 48 hours.1
How to respond to
Alter treatment in response to culture and sensitivity results.
For animals not covered in this guidance, seek microbiology advice for the most appropriate antibiotic.1
General advice
If the wound has just occurred, encourage it to bleed. Clean and irrigate the wound.1
Treatment choices
Cat or Dog bite first line prophylaxis or treatment:2 Cat or Dog bite prophylaxis or treatment if penicillin allergic:2
Co-amoxiclav* 375-625 mg tds for 7 days
Metronidazole 200-400mg tds PLUS Doxycycline 100mg bd for 7 days
For children under 12 with penicillin allergy seek microbiology advice.1
Cautions
Antiseptic cleansers are not necessary, and there is some concern that they damage tissue and delay wound healing.1
Evidence
Non-human bites that are low risk and that do not involve the hand have infection rates <2%.3
Macrolides are not recommended for animal bites because they do not adequately cover Pasteurella.2
References
1. PRODIGY – Bites – human and animal http://prodigy.clarity.co.uk/bites_human_and_animal (Accessed March 2012)
3. US Surgical Infection Society Guidelines 2009 Treatment of Complicated Skin and Soft Tissue Infections. Surgical Infections 10(5); 467-499
page 51
Skin & Soft Tissue Infections – Human Bite
When to treat
Human bites can result in serious soft tissue infection.1 Prescribe prophylactic antibiotics for all human bite wounds under 72 hours old,
even if there is no sign of infection.2 If a bite is >72 hours old and there is no sign that it has become infected, the risk of infection is likely
to be low and prophylactic antibiotics are probably not of value.2
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons, bones, the CNS;
facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds requiring closure; bites that might need
reconstructive surgery; devitalised wounds requiring debridement; bites where the severity is difficult to assess; bites with severe cellulitis;
infections not responding to treatment; people with an increased risk of infection (e.g. diabetic, cirrhotic, immunosuppressed, asplenic);
bites to poorly vascularised areas.2
Bite wounds suitable for management in primary care do not usually require closure.2
When to investigate Where infection suspected, send a pus or deep wound swab for culture before cleaning the wound and starting antibiotics.2
Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell. For infected wounds, review at
24 and 48 hours.2
Seek immediate advice from a consultant in microbiology or infectious diseases for anyone considered to be at risk of HIV, hepatitis B or C.2
Consider all people to be at risk unless the current status of the biter is known (rare).2
Consider if tetanus prophylaxis is required. Tetanus after a human bite is extremely rare.2
How to respond to
Alter treatment in response to culture and sensitivity results.
General advice
If the wound has just occurred, encourage it to bleed. Clean and irrigate the wound thoroughly with warm running water.2
Treatment choices
Prophylaxis or treatment:3
Co-amoxiclav* 375-625 mg tds for 7 daysB
Cautions
*High-risk drug for Clostridium difficile infection and should be avoided in at-risk patients
Antiseptic cleansers are not necessary and there is some concern that they damage tissue and delay wound healing.2
Evidence
Doxycycline, but not clarithromycin is active against Eikenella species, which is commonly isolated from human mouths.3
References
1. Dryden M. Complicated skin and soft tissue infection. Journal of Antimicrobial Chemotherapy. 2010; 65(3): 35-44
2. PRODIGY – Bites – animal and human http://prodigy.clarity.co.uk/bites_human_and_animal (Accessed March 2012)
If penicillin allergic:3
Metronidazole 200-400mg tds PLUS Doxycycline 100mg bd for 7 daysC
OR Clarithromycin 250-500mg bd for 7 daysC
page 52
Skin & Soft Tissue Infections – Scabies
When to treat
The main symptom is generalised itch – especially at night. Characteristic silvery lines may be seen in the skin where mites have burrowed.
Erythematous papular or vesicular lesions are often associated with the burrows.1 Typical sites include the interdigital folds, wrists, elbows
and around the nipples in women.2
Simultaneously (within 24 hours) treat the infected person and all members of the household, close contacts and sexual contacts even in
the absence of symptoms.1 Scabies persists indefinitely if not treated.1
Treat scabies that has become infected with an antibiotic.1
When to investigate Finding the mite or its products confirms, but is not necessary for making a diagnosis of scabies.1
Review if symptoms have not cleared within 6 weeks after the first application of treatment.1
Refer institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes) to the HPA.1
Treatment choices
PermethrinA+ 5% cream. Apply as described below, in two
applications, 7 days apart.3 Wash off after 8-12 hours.1
If allergy: MalathionC 0.5% aqueous liquid. Apply as described
below, in two applications, 7 days apart.3 Wash off after 24 hours.1
Apply the treatment to the whole body from the chin and ears downwards paying special attention to the areas between the fingers and
toes and under the nails. People who are immunosuppressed, the very young (under 2) and elderly people should apply the insecticide to the
whole body including the face and scalp.1 If treatment is washed off during the treatment period (e.g. hand washing), it should be reapplied.1
General advice
Itch may persist for several weeks.1
Machine wash (at 50°C or above) clothes, towels, and bed linen, on the day of application of the first treatment.1
If recurrence occurs where all contacts were treated simultaneously and treatment was applied correctly, give a course of a different
insecticide.1
Evidence
There is more evidence for the effectiveness of permethrin than malathion.1
Benzyl benzoate is regarded as too irritant, and crotamiton is ineffective compared to the recommended options.2
Crusted scabies usually only occurs in people who are immunocompromised or who have other risk factors and does not present in the
same way as classic scabies.1 There are hyperkeratotic, warty crusts, which are usually on the hands and feet but all areas of the skin may
be involved.1 Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies;
admission may be required.1
References
1. PRODIGY – Scabies http://prodigy.clarity.co.uk/scabies#261340001 (Accessed March 2012)
2. British Association of Sexual Health and HIV 2010 United Kingdom National Guideline on the Management of Scabies infestation. http://www.bashh.org/guidelines
page 53
Skin & Soft Tissue Infections – Fungal Infection – Skin
When to treat
Treat fungal skin infections with topical or oral antifungals depending on their severity and location (see below).1
Scalp infections: discuss with specialist.2
When to
investigate
Samples are not needed for uncomplicated athlete’s foot, mild infections of the groin and mild skin ringworm.2
Take samples if oral treatment is being considered; in severe or extensive skin fungal infections; for skin infections refractory to initial treatment
or when the diagnosis is uncertain.2
Scrape skin from the advancing edge of lesion. Use a blunt scalpel blade or similar. 5mm2 of skin flakes are needed for microscopy and culture.
Do not refrigerate.2
How to respond Treat if positive lab cultures. Susceptibility testing of dermatophytes is not required, as antifungal resistance is unusual and there is no known
to a positive lab correlation between antifungal susceptibilities and outcome.2
result
For non-dermatophyte moulds other than Candida sp, seek the advice of a microbiologist or dermatologist.2
General advice
Wash the affected skin daily and dry thoroughly afterwards, wash clothes and bed linen frequently, don’t share towels and wash them
frequently, wear loose-fitting clothes made of cotton.1
Treatment
choices
Dermatophyte infection:
Skin or foot:2
Topical 1% Terbinafine A+od - bd for 7-14 days A+
Groin or foot:2
Use a 1% Azole cream od - bd for 4-6 weeks
Alternative for foot only:3
Topical Undecanoates (Mycota®)B+ bd
continued for 1-2 weeks after healing
Cautions
*Following reports of heart failure, caution is advised when prescribing itraconazole to patients at high risk of heart failure.4
Do not give a corticosteroid preparation alone.1
Evidence
As terbinafine is fungicidal, one week is as effective as 4 weeks azole which is fungistatic.4AA Cochrane review found little difference between terbinafine and azoles in standard courses at 2 weeks after baseline however at 6 weeks,
treatment failure was lower with terbinafine.3
References
1. PRODIGY – Fungal skin infection: Body and groin http://www.prodigy.clarity.co.uk/fungal_skin_infection_body_and_groin#377164001 (Accessed March 2012)
2. HPA Fungal skin and nail infections 2011. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1240294785726 (Accessed March 2012)
4. BNF 63, March 2012.
Candida infection:
Azole cream 1% od - bd
continued for 1-2 weeks
after healing1
If intractable, send skin scrapings before starting oral
treatment:3
Terbinafine 250mg oral od4
Skin: 4 weeks Groin: 2-4 weeks Foot: 2-6 weeks4
OR Itraconazole4*
Skin or groin: either 100 mg oral daily for 15 days,
or 200 mg od for 7 days4
Foot: either 100mg oral once daily for 30 days
or 200mg twice daily for 7 days4
page 54
Skin & Soft Tissue Infections – Fungal Infection – Fingernail or Toenail
When to treat
Start therapy only if infection is confirmed by laboratory.1C Only 50% of nail dystrophy are fungal.2
Self care alone may be appropriate for people who are not bothered by the infected nail or who wish to avoid the possible adverse effects
of drug treatment.3
When to investigate Always send samples before starting lengthy treatment.1 Send specimens of nail clippings or scrapings for fungal microscopy and culture.3
False-negative rates are high (about 30%).3 Therefore repeat the test if the result is negative, and there is high clinical suspicion that the
nail is infected.3
How to respond to
For infections with dermatophytes use oral terbinafine or intraconazole.4
Terbinafine is more effective than azoles.4A+
If candida or non-dermatophyte infection confirmed, use oral itraconazole.4B+
General advice
Liver reactions rare with oral antifungals.4A+
For children, seek specialist advice as fungal nail infection is rare in children, and the preferred treatments are not licensed for use in
children.4C
Treatment
choices4
Superficial only:
Amorolfine 5% nail lacquer B- 1-2x / weekly
Fingernails: 6 months
Toenails: 12 months
Evidence
Treatment does not always cure the infection.3 Cure rates range between approximately 60–80%.3
The HPA Mycology Reference Laboratory recommends itraconazole for non-dermatophyte infections because although some of the
infecting organisms are not particularly susceptible to this agent in vitro, it does reach high concentrations in nail tissue. It can be given as
a pulse therapy regimen rather than continuous treatment.4
References
1. HPA Fungal skin and nail infections 2011. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1240294785726 Accessed Jan 2012
2. Roberts DT, Taylor WD, Boyle J. Guidelines for treatment of onychomycosis. British Journal of Dermatology 2003;148:402-410
3. PRODIGY - Fungal Nail Infection http://www.prodigy.clarity.co.uk/fungal_nail_infection#370858001 Accessed Jan 2012
First line:
Terbinafine A+ 250mg oral od
Fingernails: 6-12 weeks
Toenails: 3-6 months
Second line:
Itraconazole A+ 200mg oral bd for 7 days each month.
Fingernails: 2 courses
Toenails: 3 courses
page 55
Skin & Soft Tissue Infections – Varicella Zoster (chicken pox), Herpes Zoster (shingles) & Cold Sores
When to treat
For chicken pox and shingles: Pregnant/immunocompromised/neonate: Seek urgent specialist advice.1B+
Chicken pox: If started <24h of rash onset & >14 years old or severe pain, dense/oral rash, 2o household case, steroids or smoker
consider treatment.1 In a review in children and adolescents, aciclovir within 24h of rash onset shortened fever by approximately one day
and reduced the maximum number of lesions but did not reduce the complication rate.1
Shingles: Treat if <72 h of rash onset and >50 years old or if non-truncal involvement or moderate/severe pain or rash. Treat and/or
urgently refer patients with ophthalmic involvement. Immunocompetent children: antivirals not recommended.2
Cold sore: Resolve after 7–10d without treatment. Topical antivirals applied prodromally reduce duration by 12-24hrs.1
When to test
Chicken pox: Laboratory tests can be used for confirmation but are rarely required.3
Shingles: Seek specialist advice for anyone who is thought to be immunocompetent and has had two episodes of shingles or if there is
diagnostic uncertainty.2
General advice
Prescribe appropriate analgesia where necessary.2,3
Treatment
choices
First line chicken pox/shingles:
Second line for shingles if compliance a problem (as ten times cost)1
AciclovirA+ 800mg five times a day 7 days1B+
ValaciclovirB+1g tds 7 daysB+
4
Cold sore: Topical aciclovir 5% 4-hourly for 5-10 days OR
FamciclovirB+ 500mg tds 7 daysB+
Evidence1
Evidence from RCTs supports treatment for all those over 50 years to prevent the incidence of post-herpetic neuralgia.
Pregnant women are at greater risk of varicella pneumonia, and there is a risk to the foetus of congenital varicella syndrome if exposure
occurs during the first 20 weeks of pregnancy, and severe disease in the neonate if varicella is contracted a week before delivery.
References
2. PRODIGY – Shingles http://www.prodigy.clarity.co.uk/shingles (Accessed March 2012)
3. PRODIGY – Chickenpox http://www.prodigy.clarity.co.uk/chickenpox (Accessed March 2012)
4. BNF 63, March 2012
page 56
Skin & Soft Tissue Infections – Acne vulgaris
When to treat
For patients seeking treatment, topical or systemic therapy should be commenced early to prevent scarring,1 although scarring is unlikely in
mild disease.2
When to
investigate2
Refer to dermatology: people with severe acne; features that make the diagnosis uncertain; those who are at risk of developing scarring
despite treatment; people who have moderate acne that has failed to respond adequately to treatment (over a period of at least 6 months);
those with painful, deep, nodules or cysts.
People who have severe psychosocial problems, including a morbid fear of deformity or people who have suicidal ideation, should be referred
promptly to psychiatry. Refer to endocrinology or gynaecology, women suspected of having an underlying endocrinological cause of acne
(such as PCOS) that needs assessment.
General advice2 In general, it is recommended that people with acne: do not wash more than twice a day, use a mild soap or cleanser and lukewarm water,
do not use vigorous scrubbing when washing acne-affected skin, do not attempt to ‘clean’ blackheads.
Advise patients that treatments are effective but take time to work (typically 8 - 12 weeks) and may irritate the skin, especially at the start of
treatment.
Treatment
choices
First line mild/moderate:2
Benzoyl Peroxide gel, washes
or creams (2.5%, 5%, 10%)
Available OTC or on prescription
Second line moderate/severe:1,2
First line moderate/severe (awaiting referral) and scarring likely:
1,2
Oxytetracycline 500mg bd
Erythromycin 500mg bd
OR Doxycycline 50mg-100mg od1,2
If inadequate response at 3 months consider adding benzoyl peroxide.2
Consider prescribing a standard combined oral contraceptive or co-cyprindiol (Dianette) for women who require contraception.2
Evidence
There is good evidence from placebo-controlled trials that tetracycline is effective at reducing lesion counts and severity.2
There is a lack of evidence from placebo-controlled trials to verify the efficacy of erythromycin, although evidence from comparative trials
indicate it is probably as effective as tetracyclines. Oral erythromycin should be reserved for use when tetracyclines are contraindicated.2
Topical antibiotics are no more effective than benzoyl peroxide and heavy reliance on them, particularly with erythromycin, has caused
significant emergence of resistant strains of bacteria.3
References
1. BNF 63, March 2012
2. PRODIGY – Acne vulgaris http://www.prodigy.clarity.co.uk/acne_vulgaris Accessed March 2012
3. What role for topical antibacterials in acne? Drug and Therapeutics Bulletin 2010 ; 48 : 141-144
page 57
EI
Eye
Infections
Eye infections – Infective Conjunctivitis
When to treat
Acute infective conjunctivitis may affect one or both eyes. It usually presents with eye irritation or a vague foreign body sensation accompanied
by tear production, discharge (which may stick the eyelids together upon waking) and red eye.1
Infective conjunctivitis may be viral or bacterial – it is difficult to clinically distinguish between the two.1
Acute infective conjunctivitis is usually self-limiting therefore a ‘wait and see’ or delayed prescribing approach is likely to be most appropriate.1
Consider starting treatment if no improvement after 3 days.1
Consider offering a topical antibiotic if the conjunctivitis is severe.2
Clinical resolution occurs within 2-5 days in 65% of confirmed bacterial conjunctivitis cases treated with placebo.1
When to
investigate
If any of the following symptoms are present, refer the patient for specialist same-day assessment to exclude acute glaucoma, keratitis, iritis
or orbital cellulitis: Significant photophobia; reduced visual acuity; pain deep in the eye; recent eye surgery; absent or sluggish pupil response;
irregular pupils; corneal damage or opacity on fluorescein staining; restricted or painful eye movements; history of head/eye trauma.1
Swab the eye to identify the infective cause when infective conjunctivitis is hyper-acute or persistent. This is not usually considered useful for
people with acute infective conjunctivitis.2
Patients should be advised to seek medical advice if symptoms do not settle within 7 days, or if there is visual disturbance, significant eyelid
swelling, photophobia or pain in the eye.1
Treatment
choices
First line:
Second line:
ChloramphenicolB+ 0.5% drop 2-hourly for 2 days then 4-hourly (whilst awake). Add 1%
Fusidic acid 1% gel bdBD
ointment at night for severe infections or if slow to respond (incurs additional prescription charge). Continue for 48h after symptom resolution
Continue for 48h after symptom resolution.
General advice
Self-management: Bathe eyes with tepid water, wiping away from the bridge of the nose to the side. Avoid contact lenses until symptoms have
cleared. Exercise hand hygiene and avoid sharing towels or pillows.1
Evidence
Fusidic acid has less Gram-negative activity than chloramphenicol.3
A double-blind placebo-controlled RCT in children showed, at day 7, 83% clinical cure with placebo compared with 86% with
chloramphenicol.4
Delayed prescribing of antibiotics appears to reduce antibiotic use (almost 50%) with similar symptom control to immediate prescribing.5
References
1. Management of acute infective conjunctivitis. Drug and Therapeutics Bulletin 2011; 49(7): 78-80
2. http://www.prodigy.clarity.co.uk/conjunctivitis_infective#304604001 (Accessed March 2012)
4. Rose PW et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care. The Lancet 2005; 366(8479): 37-43
5. Everitt H, Little P, Smith P. A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. BMJ 2006; 333(7563): 32
page 59
DI
Dental
Infections
Dental Infections – Mucosal Ulceration and Inflammation (Simple Gingivitis)
When to treat1 Where possible manage precipitating factors.
Offer symptomatic treatment for pain, discomfort, and swelling, especially when ulcers are causing problems with eating.
If ulcers are infrequent, mild, and not interfering with daily activities (for example eating), treatment may not be needed.
When to refer1 Referral is recommended for people with a suspected underlying cause of aphthous-like ulceration, to identify and manage any underlying
disease.
Refer urgently anyone with:
Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks.
Unexplained red and white patches (including suspected lichen planus) of the mucosa that are painful, swollen, or bleeding.
Symptoms or signs related to the oral cavity that persist for >6 weeks if a definitive diagnosis of a benign lesion cannot be made.
Make a non-urgent referral for anyone with:
Unexplained red and white patches (including suspected lichen planus) of the mucosa that are not painful, swollen, bleeding.
A suspected underlying cause of aphthous-like ulceration, suggested by history, examination, or results of investigations
Particularly painful and disabling aphthous ulceration or if recurrences are frequent and severe and not adequately relieved by symptomatic
treatments.
General advice Temporary pain and swelling relief can be attained with saline mouthwash.3
Use antiseptic mouthwash if more severe pain limits oral hygiene or to prevent secondary infection.1
Treatment
choices3
Simple saline mouthwash
½ tsp salt dissolved in glass warm water
Chlorhexidine 0.2% mouthwash
(Do not use within 30mins of toothpaste)
Rinse mouth with 10mL for 1 minute bd.
Can be diluted 1:1 with water with no loss in efficacy.
Hydrogen peroxide mouthwash 6%
Rinse mouth for 2-3 minutes with 15 ml
diluted in half a glass of warm water tds.
Spit out mouthwash after rinsing. Use until lesions have resolved or less pain allows oral hygiene.3
Evidence
Evidence on antimicrobial mouthwashes for the management of aphthous ulcers is poor. The quality of studies is poor and results are not
consistent. Antimicrobial mouthwashes may reduce the duration and severity (degree of pain) of an ulcer episode, and increase the number of
ulcer-free days between episodes. However, antimicrobial mouthwashes do not seem to reduce the incidence of ulceration (number of new ulcers).
References
1. PRODIGY – Aphthous ulcer http://www.prodigy.clarity.co.uk/aphthous_ulcer (Accessed March 2012)
2. BNF 63, March 2012
3. Scottish Dental Clinical Effectiveness Programme Drug Prescribing For Dentistry 2011 http://www.sdcep.org.uk/ (Accessed March 2012)
1
page 61
Dental Infections – Acute Necrotising Ulcerative Gingivitis (ANG) and Pericoronitis (PC)
When to treat
Professional scaling and polishing, root surface instrumentation, and sometimes surgical procedures, are required.1
ANG: The mainstay of treatment is local antiseptics and hygiene measures; adjunctive antibiotics are only required in cases of systemic
involvement or where there is failure to improve following primary dental management.1,2
Commence antibiotics and refer urgently to dentist for scaling and oral hygiene advice.1
PC: Refer to dentist urgently for irrigation and debridement.2 Antibacterial treatment required only in presence of systemic features of infection,
or of trismus or persistent swelling despite local treatment.2,3
General
advice2
During the acute phase the person should, if possible, use a soft toothbrush to clean their teeth.1
While the patient is waiting for referral to a dentist prescribe analgesia for pain relief.1
Treatment
choices
First line:2,3
Metronidazole 200mg tds for 3 days in conjunction with
dental treatment.
Second line:2,3
Amoxicillin 500mg tds for 3 days in conjunction with dental treatment
(irrigation or incision and debridement).
In adults, the dose can be doubled in severe infections.2
Evidence
Trials or systematic reviews on the treatment of ANUG are awaited; therefore the recommendations are based on formal expert opinion from the
Scottish Dental Clinical Effectiveness Programme 2011.
Obligate anaerobes were isolated in 91% of cases, in a study of 35 patients with pericoronitis, and resistance to metronidazole was not evident in
any species. Amoxicillin was highly active against 91.5% of aerobes and anaerobes isolated and therefore in severe infections amoxicillin can be
added to metronidazole.4 PRODIGY found no evidence that metronidazole is more (or less) effective than amoxicillin.1
References
1. PRODIGY – Gingivitis and peridontitis http://www.prodigy.clarity.co.uk/gingivitis_and_periodontitis (Accessed March 2012)
3. BNF 63, March 2012
4. Management of Infection Guidance for Primary Care, HPA & BIA. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
page 62
Dental Infections – Dental Abscess
When to treat
Systemic signs of acute dental abscess include: pyrexia, trismus, lymphadenopathy, gross facial or ocular oedema, dysphagia, tachycardia or
rigors. Refer urgently to dentist – dental abscesses should be treated with local measures in the first instance.1
Interim treatment while waiting to see a dental practitioner may consist of advice about self-care and analgesia, with or without an antibiotic
prescription.2
Antibiotics are only recommended (in conjunction with urgent dental referral) if there are signs of severe infection, with cellulitis or systemic symptoms
or high risk of complications.2,3 Otherwise, regular analgesia should be first option until a dentist can be seen.4 Definitive surgical treatment to drain the
abscess (through incision, extraction or removal of necrotic pulp) by a dentist is the primary management of a dentoalveolar abscess.4
General
advice2
Provide advice regarding food and drink to reduce the pressure and pain of the dental abscess: avoid food or drink that may be too hot or cold;
consume cool, soft foods.
Encourage regular use of analgesics (ibuprofen and/or paracetamol is recommended if no contra-indications). Warn the individual not to exceed
the recommended or prescribed dose. Analgesics should not be used to delay appropriate dental treatment.
Advise the patient that antibiotic therapy is prescribed to reduce the spread of infection; not a substitute for dental treatment.
Treatment
choices
First line:2,4
Amoxicillin 500mg - 1g tds for 5 days
If spreading infection (lymph node involvement, or systemic signs,
i.e. fever or malaise) ADD metronidazole.4C
Cautions
Do not routinely provide repeat prescriptions or switch antibiotics in people who fail to respond to first-line treatment. Instead advise the person
to see a dental practitioner urgently.2 The failure of the antibiotic is not usually due to microbial resistance.2
Evidence
Amoxicillin and metronidazole are generally considered to be the antibiotics of choice for the management of dental abscesses. PRODIGY found
very little evidence to provide clear advice on which of the two antibiotics should be considered first-line.2
An audit in Cardiff of 112 patients with dentoalveolar infection concluded that incisional drainage appeared to produce a more rapid
improvement compared to drainage by opening of the root canal. The presence of penicillin-resistant bacteria did not adversely affect the
outcome of treatment. The observations made support surgical drainage as the first principle of management and question the value of
prescribing penicillin as part of treatment.4
The empirical use of clindamycin, clarithromycin, cephalosporins and co-amoxiclav do not offer any advantage for most dental patients and
should only be used if no response to first line drugs when referral is the preferred option.4C
References
2. PRODIGY – Dental abscess http://www.prodigy.clarity.co.uk/dental_abscess (Accessed March 2012)
3. BNF 63, March 2012.
4. Management of Infection Guidance for Primary Care, HPA & BIA. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/
Penicillin Allergy or as an adjunct to amoxicillin where there is
spreading infection or pyrexia:1,2
Metronidazole 200mg-400mg tds for 5 days
page 63
Fosfomycin Indication and Licensing
When is Fosfomycin indicated?
Lower UTI due to ESBL-producing micro-organisms or on recommendation of consultant
medical microbiologist.
Fosfomycin is not indicated for the treatment of ESBL pyelonephritis or peri-nephric
abscess (admit to hospital for IV antibiotics).
What is an ESBL?
Extended-spectrum beta-lactamases (ESBLs) are bacterial enzymes (usually plasmidmediated) that confer resistance to a broad range of beta-lactam antibiotics including
co-amoxiclav and cephalosporins.
What is Fosfomycin’s licensing status in the UK?
Fosfomycin is licensed in the UK. However no UK-packaged product is currently
available and thus all supplies must be obtained from abroad.
Where is Fosfomycin licensed?
Fosfomycin is currently licensed and can be sourced from Germany, France, Italy and
Spain.
Fosfomycin Prescribing Information
Mode of action
Fosfomycin is a bactericidal antibacterial. Fosfomycin inactivates the enzyme pyruvyl
transferase required for the biosynthesis of peptidoglycan in bacterial cell walls.
Fosfomycin is concentrated in the bladder and is active against E. coli, Proteus sp. and
Enterococci.
Pregnancy
Animal data show no teratogenic effects. Several published reports studied the efficacy
and safety of oral fosfomycin in all stages of pregnancy. In these studies fosfomycin did
not cause harm to a foetus.
Dosing: Uncomplicated UTI in females
Fosfomycin 3 gram sachet as a single oral dose is effective in the treatment of
uncomplicated lower urinary tract infections in adult females. Single dose therapy
(3 gram) was equivalent to 7-day course of norfloxacin in a randomised, blinded study.
(de Jong Z et al. 1991 Urol Int).
Contraindications
Hypersensitivity to fosfomycin.
Suspected bacteraemia.
GFR <10mL/min.
Dosing: Complicated UTI or male patients
Fosfomycin calcium 500mg capsules are licensed at 500mg-1gram every 8 hours.
Fosfomycin 3g sachets have been administered once every 48 hours.
A 7-day course (minimum) is recommended for male patients and for complicated lower
urinary tract infections (e.g. catheter-associated UTI) without bacteraemia
(Moroni M 1987 Eur Urol).
Interactions
No significant drug-drug interactions.
Food intake can slow down the absorption of fosfomycin with, as a result, lower
concentrations in the urine. Fosfomycin should, therefore, be administered while fasting
or 2 or 3 hours before meals.
Dosing in renal impairment
GFR 10-50mL/min: 3gram single dose or 3grams every third day.
Side Effects
More common than 1%:
Diarrhoea/Abdominal pain (10%)
Nausea/Indigestion (5%)
Headache (3-10%)
Skin rashes (1%)
Vaginitis (5%)
Asthenia (1%)
Rare Serious Reactions:
Serious hypersensitivity reactions
Impairment of hepatic function
Aplastic anaemia
page 65
Fosfomycin Supplies
Fosfomycin is not available commercially as a licensed product in the UK. Currently the only means of obtaining fosfomycin is to order from a ‘specials’ supplier.
There will be a delay in obtaining the product in the community setting and careful consideration needs to be given when prescribing and supplying to patients who
may need treatment more urgently. The patient should be advised to consult GP if symptoms worsen whilst awaiting supply.
Brands: These include - MONURIL® (Zambon – Italy; Netherlands) and MONUROL® (Pharmazam – Spain, USA, Hong Kong).
Fosfomycin can be imported via IDIS World Medicines. There is usually a delay of 48hours between order and delivery. IDIS World Medicines: IDIS House,
Churchfield Road, Weybridge, Surrey, KT13 8DB, Tel: 01932 824000; Fax: 01932 824226; Web: www.idispharma.com
page 66
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